Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral appliance to be provided by an out of network provider.
You asked the Plan to pre-approve an oral appliance from an out-of-network provider. You say that the provider recommended is not a dentist and a dme supplier. The Plan denied your request. The Plan says an oral appliance can be provided by a contracted provider.
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 an oral appliance to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that
the Plan requires you to receive care from providers who are part of your primary care physician's (PCP)
specialty network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 contract with
the Plan also says that the Plan requires the enrollee to receive care from providers who are part of the
enrollee's primary care physician's (PCP) specialty network.
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. We found no exception that would require the
Plan to pre-approve the requested physician's services. Therefore, we decided that the Plan does not have to
pre-approve the requested physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 23, 2019 to November 1, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration because your provider informed you that they had other patient's from your plan. The Plan denied your request. The Plan says these services were denied because you did not use a network provider for your chiropractic 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 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 medical services provided on October 23, 2019 to November 1, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for facet joint injections (64633 and 64634) provided on December 9, 2019.
You asked the Plan to pay for the injections. 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 services 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 64633 is destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint. The CPT Code Manual definition of code 64634 is destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure). 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 injections. Our reviewer says that CPT code 64633 does not meet criteria for billing or reimbursement consideration. The medical records provided do not include a procedural note to detail and validate that this service was performed. Our reviewer found CPT code 64634 does not meet criteria for billing or reimbursement consideration. CPT code 64634 is an add-on code and is only eligible for payment when one of its primary codes is also eligible for payment. 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 injections have not been met. Therefore, we decided that the Plan does not have to pay for facet joint injections (64633 and 64634) provided on December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient practitioner visit provided on August 28, 2019 to September 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient practitioner visit. You say that the member was moving to another state. The Plan denied your request. The Plan says these services were not urgent. The plan says that 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 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 outpatient practitioner visit provided on August 28, 2019 to September 6, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve toilet paper, paper towels, alcohol, bleach, masks and gloves.
You asked the Plan to pre-approve the DME supplies. You say that you would like reconsideration because these supplies are necessary and not available in stores. The Plan denied your request. The Plan says these supplies are not covered because they are convenience items.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve toilet paper, paper towels, alcohol, bleach, masks and gloves.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0480 provided on
October 1, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 80307 and G0480 are not supported in the medical record. Specifically, the
documentation does not support evidence of an established relationship between the enrollee and the ordering
physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not
been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and
G0480 provided on October 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Continuous Glucose Monitor (CGM) (A9278),
external transmitter (A9277) and disposable sensor (A9276).
You asked the Plan to pre-approve the CGM and accessories. You say that the CGM is medically necessary.
The Plan denied your request. The Plan says rules for coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they
are medically reasonable and necessary and replace a blood glucose monitor.
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 CGM and accessories. Our reviewer
says that coverage criteria has not been met. Our physician reviewer found while the enrollee is taking a
medication that can cause low blood sugar and the CGM may be beneficial, Medicare coverage criteria requires
an enrollee check their blood sugar at least 4 times daily and be insulin dependent for a CGM to be covered.
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 CGM and accessories have not been met. Therefore, we decided that the
Plan does not have to pre-approve a Continuous Glucose Monitor (CGM) (A9278), external transmitter
(A9277) and disposable sensor (A9276).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omega-3 acid ethyl esters.
You asked the Plan to pre-approve Omega-3 acid ethyl esters. You say that the enrollee needs an additional medication that does not have adverse effects. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D prescription drug plan.
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 Omega-3 acid ethyl esters.
Benefits for Omega-3 acid ethyl esters 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA 1 and 2 testing for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says there is no personal history of breast, ovarian, or pancreatic cancer, so this testing is considered screening.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, BRCA 1 and 2, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve BRCA 1 and 2 testing for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 5, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because you suffered from a rash. 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 each specialist visit. You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrocentesis (20611) provided on November 18, 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 services 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 (e.g., 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 medical records provided do not include permanently recorded images in order to validate the services billed. 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 November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on January 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you have seen this doctor in the past. You say that you would like this claim reprocessed and approved for payment. 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 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 an office visit provided on January 21, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for three dental extractions and dentures provided on November 21, 2019.
You asked the Plan to pay for three dental extractions and dentures. The Plan denied your request. The Plan says that the extraction benefit is exhausted and dentures 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. The Plan covers two dental extractions per calendar year. We looked at the file and Plan rules. The file indicates the Plan has already covered two extractions on this same date of service. The Plan contract also confirms dentures are not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of three dental extractions and dentures have not been met. Therefore, we decided that the Plan does not have to pay for three additional dental extractions and dentures provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic services you received from a chiropractor on November 15, 2019.
You asked the Plan to pay for the therapeutic services. You say that as a result of the therapeutic exercises, you are relieved of back pain. The Plan denied your request. The Plan says chiropractic care other than manual manipulation of the spine is not a covered benefit.
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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the therapeutic services you received from a chiropractor on November 15, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for hearing aids (V5299) provided on August 7, 2019.
You asked the Plan to pay for the hearing aids. You say that you would like reconsideration because you have
supplemental benefits for hearing aids. The Plan denied your request. The Plan says that the hearing aid benefit
has been exhausted.
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Please note, we have made multiple requests for an EOC. Without this
documentation, we are unable to verify the member's hearing aid benefits. There is insufficient information to
substantiate the Plan's denial of services. Therefore, we decided that the Plan has to pay for hearing aids
(V5299) provided on August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that an authorization was not required. The Plan denied your request. The Plan says there is no network deficiency for the services, and alternate network providers were found.
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 on December 17, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided on December 27, 2019.
You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services billed are not separately payable.
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 99232 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. We find that CPT code 99232 is not supported in the medical record. Specifically, this service was provided within the 90-day post-operative period. This post-operative service is not allowed because it was included in the payment for the surgical procedure. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided on December 27, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on October 30, 2019.
You asked the Plan to pay for the ambulance service and ground mileage. You say that hospice was termed on October 16, 2019. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on October 16, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance service and ground mileage provided on October 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient consultation (99254) provided on July 31, 2019.
You asked the Plan to pay for the inpatient consultation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service has been billed inappropriately and is not supported by the documentation submitted.
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 code 99254 is not supported in the record. Specifically, CPT code 99254 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the inpatient consultation have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient consultation (99254) provided on July 31, 2019.