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

We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on September 24, 2019 by an out of network (OON) provider.You asked the Plan to pay for the Cxbladder test. You say that this should be covered.The Plan denied your request. The Plan says this service was not authorized.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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on September 24, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided on August 14, 2019.
You asked the Plan to waive the coinsurance for the DME. 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 2019 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).
Review of the file show that you received DME provided on August 14, 2019. You are asked to pay 20%
coinsurance for DME. 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 coinsurance for the DME provided on August
14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for mechanical traction therapy (97012) provided on September 4, 2019.You asked the Plan to pay for mechanical traction therapy. You say that this should be covered.The Plan denied your request. The Plan says this is not covered by Medicare or the Plan.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.Therefore, we decided that the Plan does not have to pay for mechanical traction therapy (97012) provided on September 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aid repair/modification (V5014) provided on October 8, 2019.
You asked the Plan to pay for the hearing aid repair/modification. You say that you have no record of having filed a claim for hearing aid benefits since March 2016. The Plan denied your request. The Plan says this request exceeds the hearing aid benefit limit.
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 has $500 hearing aid reimbursement allowance every three years. You pay all charges over the $500 hearing aid allowance. The records show that you were reimbursed $225 on 5/17/17 for the repair of the right hearing aid and $275 on 11/23/19 for repair of the left hearing aid. Therefore, the $500 benefit is exhausted. Based on this information, we decided that the Plan's rules for coverage of the hearing aid repair/modification have not been met. Therefore, we decided that the Plan does not have to pay for hearing aid repair/modification (V5014) provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services for a consultation to be provided
You asked the Plan to pre-approve the physician's services for a consultation. You say that you would feel more confident having this physician do the surgery because the surgery is very invasive. The Plan denied your request. The Plan says the requested services are available in-plan.
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 services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is not providing these services and is not making arrangements to provide these services. Therefore, we decided that the Plan does not have to pre-approve physician's services for a consultation
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (K0822).
You asked the Plan to pre-approve the power wheelchair. You say that you need a lighter wheelchair for easier transport. The Plan denied your request. The Plan says you previously received the same item that is still within the 5-year RUL.
The Plan must follow Medicare rules. Medicare rules say that the RUL of durable medical equipment is determined through program instructions. In the absence of program instructions, the MAC may determine the RUL of equipment, but in no case can it be less than five years. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that you received the same or similar power wheelchair in July 2019. This power wheelchair is still within the 5-year RUL and the documentation submitted does not show that the power wheelchair is irreparably worn, irreparably damaged, or that you have had a change in medical condition to warrant the new power wheelchair at issue. Based on this information, we decided that Medicare rules for coverage of the power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0822).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Zynex NexWave transcutaneous electrical nerve stimulation (TENS) device.You asked the Plan to pre-approve a TENS device. You say that you need a TENS device for low back pain.The Plan denied your request. The Plan says you are not in an approved clinical study.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a TENS device have not been met.Therefore, we decided that the Plan does not have to pre-approve a Zynex NexWave transcutaneous electrical nerve stimulation (TENS) device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns for tooth #'s 11, 14, 3, & 6 and pontics for tooth #'s 12, 13, 4, & 5.
You asked the Plan to pre-approve the retainer crowns and pontics. You say that the enrollee needs these services in order to be able to eat properly. The Plan denied your request. The Plan says the services are not medically necessary.
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 Plan covers the retainer crowns and pontics when the services are medically necessary and reasonable. 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 retainer crowns and pontics. Our reviewer says that the services are not medically necessary. Our physician reviewer found the criteria for fixed bridges to replace missing tooth #'s 4, 5, 12 and 13 have not been met since the coverage for fixed bridges includes replacement of a single maxillary anterior tooth or two mandibular anterior teeth when no posterior teeth are missing. Our reviewer also found that the teeth to be replaced are posterior teeth, and there was no indication that a removable partial denture could not be used to replace the missing teeth. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the retainer crowns and pontics have not been met. Therefore, we decided that the Plan does not have to pre-approve retainer crowns for tooth #'s 11, 14, 3, & 6 and pontics for tooth #'s 12, 13, 4, & 5.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ambulance services.
You asked the Plan to pre-approve the ambulance services. You say that you need to use an ambulance to get to your doctor appointment. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pre-approve are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pre-approve the ambulance services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.
You asked the Plan to pre-approve massage therapy. You say that you need this service. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for catheter placement (93461) provided on August 24, 2019.
You asked the Plan to pay for the catheter placement. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted records do 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 93461 is catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography . 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 catheter placement. Our reviewer says that CPT code 93461 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical record submitted does not include enough specific information to validate that the service provided meets all definition requirements to bill CPT code 93461 for the service that was rendered. 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 catheter placement have not been met. Therefore, we decided that the Plan does not have to pay for catheter placement (93461) provided on August 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.
You asked the Plan to pre-approve a grab bar. You say that you need the grab bars so you don't put too much pressure on your knee. The Plan denied your request. The Plan says the requested item is not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ambulance transport provided on September 7, 2019.You asked the Plan to waive the coinsurance for the ambulance transport. You say that you did not want to take the ambulance.The Plan denied your request. The Plan says that the copayment applies for ambulance services.The rules say a plan must disclose to its enrollees in clear, accurate terms allcost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 copayment for Medicare-covered ambulance services per day. You have been asked to pay a $125 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered ambulance services per day 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 coinsurance for the ambulance transport provided on September 7, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a follow-up visit to be provided by an out of network (OON) provider.You asked the Plan to pre-approve a follow-up visit. You say that you want to go to requested provider.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 a follow-up visit to be provided 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 walker, heavy duty, wheeled, rigid or folding, any type.You asked the Plan to pre-approve a walker (E0149). You say that the enrollee needs a heavy duty walker.The Plan denied your request. The Plan says the enrollee does not weigh more than 300 pounds.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a walker (E0149) have not been met.Therefore, we decided that the Plan does not have to pre-approve a walker, heavy duty, wheeled, rigid or folding, any type.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device (22869 and 22870).You asked the Plan to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device. You say that this is covered by Medicare.The Plan denied your request. The Plan says this is experimental.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 insertion of interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device is experimental. More research is needed to show that it is safe and effective.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 insertion of interlaminar/interspinous process stabilization/distraction device have not been met.Therefore, we decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device (22869 and 22870)
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 January 3, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 January 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retainer crown (D6740).
You asked the Plan to pre-approve the retainer crown. You say that you need this service because your top teeth are decaying, and some are broken. You also say that you need this service so that you are able to eat and chew. The Plan denied your request. The Plan says this service is not a covered benefit.
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 retainer crown (D6740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic.You asked the Plan to pre-approve the pontic. You say that you need this service because your top teeth are decaying, and some are broken. You also say that you need this service so that you are able to chew and eat.The Plan denied your request. The Plan says this service is not a covered benefit.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 pontic.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a TENS unit (E0730).
You asked the Plan to pre-approve the TENS unit. The Plan denied your request. The Plan says Medicare coverage criteria for the TENS unit have not been met.
The Plan must follow Medicare rules. Medicare rules say that a TENS unit is not reasonable and necessary for the treatment of chronic low back pain, and is only covered when the enrollee is enrolled in an approved clinical study. We looked at the file and Medicare rules. In this instance, the TENS unit was requested for the diagnosis of chronic low back pain, and the enrollee is not enrolled in an approved clinical study. Based on this information, we decided that Medicare rules for coverage of the TENS unit have not been met. Therefore, we decided that the Plan does not have to pre-approve a TENS unit (E0730).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve (CGM) sensors.
You asked the Plan to pre-approve CGM sensors. You say that the enrollee needs sensors for a CGM. The Plan denied your request. The Plan says criteria for a CGM is not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and supplies are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. The enrollee is not insulin injectioning three or more times a day and tests twice a day. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve (CGM) sensors.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction to be provided by an oral surgeon.
You asked the Plan to pre-approve the extraction. You say that the work you need done is medically necessary due to pre-existing cardiac issues. The Plan denied your request. The Plan says services are only covered when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon are 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 only covered when they are received by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve an extraction to be provided by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a compounded drug (J7999x90 and J7999x40) provided on April 25, 2019.You asked the Plan to pay for the drugs. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says only one unit is appropriate to bill for this code.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 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 drugs. Our reviewer says that J7999 KD billed at 90 units is inappropriate and cannot be considered for reimbursement. J7999 KD billed at 40 units is also inappropriate and cannot be considered for reimbursement. Our reviewer found When billing a compounded drug, you must submit a quantity billed as "1" to the health plan for reimbursement consideration, otherwise, the claim will be denied.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 drugs have not been met. Therefore, we decided that the Plan does not have to pay for a compounded drug (J7999x90 and J7999x40) provided on April 25, 2019.