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

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 4, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services 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 the medical services provided to the enrollee by an out-of-network provider on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says both thermal and cooled manners of genicular radiofrequency ablation are still being 
studied to determine if these are safe and effective alternative treatments to standard therapies for knee pain due 
to osteoarthritis or in the setting of replacing or significantly delaying total knee arthroplasty. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is an experimental and investigational procedure that is the subject of several ongoing clinical trials. 
No learned society has adopted this procedure as part of a practice guideline. Therefore, 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the diagnostic services provided from January
3, 2020 to March 18, 2020.
You asked the Plan to waive the copays for the services provided. You say that the location was recommended
as a free-standing facility. The Plan denied your request. The Plan says the claims were processed correctly.
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 file shows that you received x-rays on January 3, 2020. A $95 copay was applied. The file shows that you
received a computed tomography (CT) scan provided on March 18, 2020. A $275 copay was applied. The
services fall within the outpatient diagnostic tests 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
copays for the diagnostic services provided from January 3, 2020 to March 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a motion assist device (L8702). You asked the Plan to pre-approve the motion assist device. You say that you would like reconsideration because the brace will replace your elbow and hand function. The Plan denied your request. The Plan says no documentation has been submitted to show that this orthosis would be preferred or more effective than any traditional upper orthosis types that are covered by Medicare. 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 motion assist device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of your rehab or progress in either motor recovery or functional status. The provided documents do not support via, history, exam findings, and the treatment plan past and current from your treating rehab professionals for the medical necessity for this device. 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 motion assist device have not been met. Therefore, we decided that the Plan does not have to pre-approve a motion assist device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis (20611) provided on October 31, 2019. 
 
You asked the Plan to pay for the arthrocentesis. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the service billed. 
 
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 20611 is arthrocentesis, aspiration and/or injection, major 
joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording 
and reporting. 
 
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 arthrocentesis. Our reviewer says that CPT code 20611 
does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation did 
not include permanent recording and reporting in the procedure report. 
  
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 arthrocentesis have not been met. Therefore, we decided that the Plan does 
not have to pay for arthrocentesis (20611) provided on October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S0207) provided on July 20, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a Medicare-covered benefit. The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code S0207 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for 
reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (S0207) provided on July 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lens (V2781), lens, polycarbonate or equal
(V2784), tint, photochromatic, per lens (V2744) and scratch resistant coating (V2760) purchased on March 11,
2020.
You asked the Plan to pay for the eyewear. You say that the provider did not get paid in full. The Plan denied
your request. The Plan says upgrades on lenses are not covered by Medicare. The Plan states there is no
supplemental plan benefit beyond the standard frames and lenses covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and
eyewear.
The plan allows coverage for eyewear after cataract surgery however covered eyeglasses after cataract surgery
only includes standard frames and lenses as defined by Medicare; any upgrades are not covered (including, but
not limited to, deluxe frames, tinting, progressive lenses or anti reflective coating). Therefore, we decided that
the Plan does not have to pay for progressive lens (V2781), lens, polycarbonate or equal (V2784), tint,
photochromatic, per lens (V2744) and scratch resistant coating (V2760) purchased on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on January 9,
2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the 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 physician services provided to the enrollee on January 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on March
11, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not have to
pay for this. The Plan denied your request. The Plan says that the copayment is a contractual obligation that
you agreed to pay upon enrolling with the Plan.
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 $225
copayment for each Medicare-covered one-way trip by ground transportation.
You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls
within the Medicare-covered one-way trip by ground transportation 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 ambulance transport provided on March 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on September 19, 2019. You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed. 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 HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found of note, the Custom Toxicology profile document submitted contains no patient identifying information. The submitted Laboratory Requisition indicates that a ToxProtect repeat and Toxicology Profile R093 Panel was requested. The submitted documentation does not itemize what tests are included in this panel. The review indicates that the records do not support the above denied codes. The records do not contain a valid physician order or requisition to support the denied codes. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on December 14, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says payment is included in the global surgical package.
The Plan must follow Medicare rules. The rules say that postoperative services are included in the global
surgical package.
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 99222. The file
shows that the services were billed within the 90 day global surgical period for major procedure 47562
performed on October 25, 2019. Payment for the hospital services at issue is included in the global surgical
package for the major procedure. Therefore, we decided that the Plan does not have to pay for the initial
hospital care rendered on December 14, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out of network provider on January 21, 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 this service was rendered by an out of network provider, without prior authorization. The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The service at issue in this appeal was not provided in an emergency or urgent care situation. The service was not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out of network provider on January 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing provided to the enrollee on January 27, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this test is considered experimental and investigational, as there is not enough proof in medical 
studies to support that the testing requested accurately assesses or significantly improves health outcomes 
and/or performs better than an existing standard of care. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the testing 
at issue in this case was not medically reasonable or necessary. Our physician reviewer found the enrollee is 
noted to have prostate cancer. Genetic testing is not necessary to either diagnose the cancer or to determine 
what type of treatment should be provided. Therefore, the requested/provided testing is not medically necessary 
or reasonable. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for testing provided to the enrollee on January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown (codes D2740) for tooth #30. 
 
You asked the Plan to pre-approve the crown. You say that you consider the bone loss to be more than 25%, 
tooth #30 is firm, and does not have mobility. You also say that the tooth structure can support a root canal. 
The Plan denied your request. The Plan says this is not a covered procedure. 
 
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. The only crowns that are covered under the enrollee's plan are codes 
D2750, D2751, and D2752. Therefore, we decided that the Plan does not have to pre-approve the crown (codes 
D2740) for tooth #30.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 92015) provided on January 13, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered
service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "N" under the Physician Fee
Schedule indicates that the code in question is non-covered.
We looked at the file and Medicare rules. CPT code 92015 is assigned a status indicator of "N" under the
Physician Fee Schedule, which means that this code is non-covered. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for the services (CPT 92015) provided on January 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myolyn Myocycle Home FES Cycling Therapy System, for the enrollee.
You asked the Plan to pre-approve Myolyn Myocycle Home FES Cycling Therapy System. You say that the durable medical equipment is medically necessary. 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 Myolyn Myocycle Home FES Cycling Therapy System have not been met. The Medicare rules say that coverage of NMES to treat muscle atrophy is limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy. Some examples would be casting or splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, and hip replacement surgery (until orthotic training begins). As the service is non-covered, equipment for home use to provide the service is also non-covered. Therefore, we decided that the Plan does not have to pre-approve Myolyn Myocycle Home FES Cycling Therapy System, for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you feel safe in this facility. You say that 
other facilities are too far. The Plan denied your request. The Plan says there are multiple in-network providers 
within 11 miles of the member's residence; therefore, this has been correctly 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 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 
physical therapy to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional non-emergent transportation trips. You asked the Plan to provide additional non-emergent transportation trips. You say that you need to see several doctors and attend rehabilitation once every three months. The Plan denied your request. The Plan says you are only eligible for 24 one-way trips within a 60 mile radius. 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. There are up to 24 one-way trips in the supplemental transportation services benefit. The 25th trip and beyond is not a covered benefit. Your EOC states, "routine transportation to plan approved health-related locations is covered for up to 24 one-way trips per calendar year (limit to ground transportation only). Each one-way trip must not exceed sixty (60) miles based on the most efficient route. A single trip is considered one-way and a round trip is considered two (2) trips." Therefore, we decided that the Plan does not have to provide additional non-emergent transportation trips.