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

We decided that the Plan does not have to pre-approve private duty nursing services for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary given the provided documentation.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the private duty nursing services at issue in this case are medically reasonable and necessary as private duty nursing services are not a Medicare covered benefit. 

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 pre-approve private duty nursing services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the current research does not support the use of this device for long-term relief of back and leg pain.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on June 29, 2020, to July 28, 2020.

You asked the Plan to waive the copayment for specialist services. You say that you were told that you would not have a copayment for this. The Plan denied your request. The Plan says the correct copayments have been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for physician/practitioner services/specialty physician. 

You have been asked to pay a $45 copayment for each specialist visit. The total amount you are being asked to pay is $90 ($45 x 2 visits = $90). Specialist services fall within the physician/practitioner services/specialty physician 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 specialist services provided by a participating provider on June 29, 2020, to July 28, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee on January 10, 2020.

You asked the Plan to pay for home health services. You say that this should be processed as in-network services. The Plan denied your request. The Plan says a RAP was not submitted for these services.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the record does not show that a RAP claim was submitted for these services. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee on January 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee continues to receive acute critical care services and these services have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving that would be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image
(D0230 x2) received December 1, 2020.

You asked the Plan to pay for the two intraoral radiographic images. You say that the requested services should
be covered by the Plan. The Plan denied your request. The Plan says these services exceed your benefit's
frequency limitation.

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 exceed
the benefit frequency limitation set by the Plan. The Plan agreed to cover one intraoral x-ray on the date of
service and therefore, the two remaining intraoral x-rays exceed the limitation of one per calendar year.
Therefore, we decided that the Plan does not have to pay for the intraoral - periapical each additional
radiographic image (D0230 x2) received December 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for routine transportation.

You asked the Plan to pre-approve additional mileage. The Plan denied your request. The Plan says this requested exceeds the benefit limit.

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. The Plan covers routine transportation up to 75 miles per one-way trip. 

We looked at your request, the records in the case file, and the rules. The requested additional mileage will exceed the routine transportation benefit limit of 75 miles per trip. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on December 1, 2020.

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 procedure code 99214 is not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.

The provider submitted a claim for procedure codes 99214 and 11310. Code 99214 is a column II code with a
modifier indicator of 1 when billed with column I code 11310. Code 99214 was not billed with an appropriate
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the office
visit rendered on December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frenulectomy (D7960) and therapeutic parenteral drugs
(D9612) provided on November 5, 2020.

You asked the Plan to pay for the frenulectomy and therapeutic parenteral drugs. You say that these services
were necessary, and you believe they should be covered. The Plan denied your request. The Plan says these
services 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 not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
frenulectomy (D7960) and therapeutic parenteral drugs (D9612) provided on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the exam provided on January 13, 2021.

You asked the Plan to pay for cervical or vaginal cancer screening (G0101). You say that you received a card in the mail requesting you to make an appointment. The Plan denied your request. The Plan says it had not been 24 months since your last covered exam.

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 cervical or vaginal cancer screening (G0101) have not been met. Therefore, we decided that the Plan does not have to pay for the exam provided on January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on October 21, 2020.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this testing is correct, because molecular genetic
screening testing is not a Medicare benefit for the diagnoses listed and was performed for screening purposes.

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 tests at issue in this appeal, genetic testing, were requested solely screening purposes. Medicare does not
cover these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic
testing provided on October 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for sales taxes and valet parking provided from May 30, 2020, through July 11, 2020.

You asked the Plan to pay for lodging per diem not otherwise specified, sales tax, and non&#8208;covered item or service provided from May 30, 2020, through July 11, 2020. You say that the night of his transplant, your wife and adult son stayed on a hotel room each for $49.00 plus tax and you paid $15 per person for parking. You say that the Plan only reimbursed you $49.00, and you feel that you should be reimbursed fully for all out of pocket cost of lodging and travel. The Plan denied your request. The Plan says contractors do not make any additional payment for sales taxes and do not make adjustments in fees to reflect local changes in tax rates. In addition, valet parking is not listed as a reimbursable expense under the Inpatient Hospital Care benefit,

The Plan contract says if the Plan provides transplant services at a distant location (outside of the service area) and the member chooses to obtain transplants at a distant location, we will arrange or pay for appropriate lodging and transportation costs for the member and one companion. The reimbursement for transportation costs are while the member and their companion are traveling to and from the medical providers for services related to the transplant care. 

We looked at the file and the Plan's rules. The Plan does not cover sales taxes and valet parking under the Inpatient Hospital Care benefit. Therefore, we decided that the Plan does not have to pay for pay for sales taxes and valet parking provided from May 30, 2020, through July 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consult to be provided by an out of network provider.

You asked the Plan to pre-approve a consult with an out of network provider. You say that the enrollee wants to see the surgeon that performed the surgery. The Plan denied your request. The Plan says they have in-network providers who can meet the enrollee's needs.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a consult to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a therapeutic glucose continuous monitor system provided on
December 28, 2020.

You asked the Plan to pay for a therapeutic glucose continuous monitor system. You say that the Plan should
pay this claim. The Plan denied your request. The Plan says the documentation submitted did not include Proof
of Delivery or a Delivery Ticket to indicate the specific supplies.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.

The record does not contain a valid proof of delivery for the supplies provided in this case. There is no itemized
delivery ticket or itemized shipping invoice in the file. The record shows that the Plan made several attempts to
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay
for a therapeutic glucose continuous monitor system provided on December 28, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on July 16, 2020.

You asked the Plan to waive the copayment for an emergency room visit. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for emergency care. 

You have been asked to pay a $50 copayment for an emergency room visit. The correct copayment has been applied to the services that were provided. An emergency room visit falls within the emergency care 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 an emergency room visit provided by a participating provider on July 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting
from September 23, 2020, to September 24, 2020.

You asked the Plan to pay for the self-administered drugs. You say that these drugs were not self-administered.
You say that you were hospitalized for diverticulitis for 3 days. You also say that these drugs were
administered intravenously per your doctor's orders. The Plan denied your request. The Plan says the drugs you
received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare
Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part
B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 in an outpatient setting from September 23, 2020, to September 24, 2020.

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 pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on December 1, 2020 by an OON provider.

You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you would like these services to be covered. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits.

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 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on December 1, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) and two core buildups, including any pins when required (D2950 x2).

You asked the Plan to pre-approve the crown and core buildups. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services are not covered under your benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) and two core buildups, including any pins when required (D2950 x2).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 6, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting.
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 11, 2020.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you feel that this service should be covered. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.

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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on December 7, 2020 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 11, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zarxio.

You asked the Plan to pre-approve Zarxio. The Plan denied your request. The Plan says that the enrollee's treatment plan has low risk for affecting white blood cell count.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Zarxio. Our physician reviewer found that the requested use of Zarxio is FDA-approved for the enrollee's diagnosis. The enrollee has chemotherapy induced neutropenia. The requested use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zarxio have been met. Therefore, we decided that the Plan has to pre-approve Zarxio.

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.