Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a family psychotherapy session (90847) provided on September 17, 2020
You asked the Plan to pay for a family psychotherapy session. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with the correct 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. In this case, the CPT Code Manual definition of code 90847 is family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes. We find that CPT code 90847 is not supported in the medical record. Specifically, the records show that only the enrollee was present for the session on this date of service. Based on this information, we decided that Medicare rules for coverage of a family psychotherapy session have not been met. Therefore, we decided that the Plan does not have to pay for a family psychotherapy session (90847) provided on September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on September 30, 2020.
You asked the Plan to pay for the office visit. You say that the medical information should be reviewed for reconsideration of the previous decision. The Plan denied your request. The Plan says the service provided is available in-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 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 had network providers available who could have provided 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 office visit provided by an out-of-network provider on September 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional prosthetic features (L6881, L6882, L7499).
You asked the Plan to pre-approve the additional prosthetic features. You say that the features are medically
necessary. The Plan denied your request. The Plan says these codes cannot be separately approved.
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 the requested features are not separately payable. Specifically, the base prosthetic code includes
all features. Individual features cannot be unbundled. Based on this information, we decided that Medicare
rules for coverage of the additional prosthetic features have not been met. Therefore, we decided that the Plan
does not have to pre-approve additional prosthetic features (L6881, L6882, L7499).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. We looked at the file and Medicare rules. The records show that the enrollee is not treated with three or more insulin injections per day. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the out-of-network
provider.
You asked the Plan to pre-approve the physical therapy to be provided by the out-of-network provider. The
Plan denied your request. The Plan says the service is available within the primary network and your condition
is not an emergency.
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 physical
therapy to be provided by the out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from September 30, 2020, to October 6, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you had a continuous hospital stay and disagree with the second inpatient copayment. 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 $315 copayment for days 1-5 for inpatient hospital care. A transfer to a separate facility type is considered a new admission. The record shows that you had an inpatient hospital stay from September 30, 2020, to October 6, 2020. This is considered a new inpatient hospital admission. Therefore, you are responsible to pay a $315 copayment for days 1-5 (September 30, 2020, to October 4, 2020). $315 (copayment) x 5 (inpatient days) = $1,575. You have been asked to pay the total copayment amount of $1,575 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 inpatient hospital stay from September 30, 2020, to October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on
December 4, 2020.
You asked the Plan to pay for the home visit. You say that the physician depends on the hospital staff to verify
eligibility and obtain proper authorization. You say that the doctor should not be penalized, and the claim
should be considered for payment. The Plan denied your request. The Plan says this provider is not a network
provider with the Plan and the services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the home visit provided by an out-of-network
provider on December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on November 12, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you have never been charged more than a $50 copayment in the past and disagree with the additional charges. 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 20% coinsurance for Medicare Part B prescription drugs. The record shows that you received a Medicare Part B drug on November 12, 2020. The total allowed amount is $2,432 and 20% of that is $486.40. You have been asked to pay the total coinsurance amount of $486.40 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 a Medicare Part B drug provided on November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant (D6010), bone graft at time of implant placement (D6104), and problem focused limited oral evaluation (D0140) provided on December 7, 2020, and December 11, 2020.

You asked the Plan to pay for the endosteal implant, bone graft, and problem focused limited oral evaluation. You say that you believe these services should be covered. The Plan denied your request. The Plan says the endosteal implant and bone graft are not covered benefits under your dental plan. The Plan also says that the problem focused limited oral evaluation exceeds the frequency limitation in 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 surgical placement of implant body: endosteal implant (D6010) and bone graft at time of implant placement (D6104) are not among those covered under this benefit. The contract says that problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on November 11, 2020 and your problem focused limited oral evaluation (D0140) had been exhausted. Therefore, we decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant (D6010), bone graft at time of implant placement (D6104), and problem focused limited oral evaluation (D0140) provided on December 7, 2020, and December 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vest airway clearance system (E0483).
You asked the Plan to pre-approve the Vest airway clearance system. You say that you are requesting an appeal
of this denial based on the enclosed medical documentation. The Plan denied your request. The Plan says the
enrollee does not meet the criteria as there is no documentation of cystic fibrosis or bronchiectasis.
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to
pre-approve the Vest airway clearance system (E0483).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit and laboratory tests to be provided by an out-of-network provider.

You asked the Plan to pre-approve an office visit and laboratory tests. You say that you have been receiving cancer treatment with this oncologist for 18 months and do not want to switch doctors. The Plan denied your request. The Plan says you must receive your care from a network provider and in-network providers are available.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 

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 an office visit and laboratory tests. Our reviewer says that you are not receiving any active treatment that makes it medically necessary for you to continue care with an out-of-network oncologist. Our physician reviewer found there are in-network oncologists available to treat your condition and care can be safely transitioned to an in-network specialist.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an office visit and laboratory tests have not been met. Therefore, we decided that the Plan does not have to pre-approve an office visit and laboratory tests 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 seat lift mechanism (E0627) and an unlisted service (99199) provided on November 14, 2020.
You asked the Plan to pay for a seat lift mechanism and an unlisted service. You say that you were never told to obtain the requested items from a medical store. The Plan denied your request. The Plan says the provider of the requested items does not participate in Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism (E0627) and an unlisted service (99199) provided on November 14, 2020.
Your complaint about not receiving adequate instruction about participating suppliers is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on November 13, 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 providers should use CPT 81479 for these services.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 Comprehensive Genomic Profile (CGP) testing provided to the enrollee on November 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional transportation trips.

You asked the Plan to provide additional transportation trips. You say that you cannot drive and it is too expensive for you to take a cab. The Plan denied your request. The Plan says your transportation benefit only covers 6-one way trips per year.

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 of 6 one-way trips to plan approved locations.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide additional transportation trips.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Euflexxa.

You asked the Plan to pre-approve Euflexxa. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires
a trial of Orthovisc and Monovisc before it will approve Euflexxa.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

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 Euflexxa. Our reviewer says that the
enrollee does not meet the Medicare criteria for a step therapy exception for Euflexxa. Our physician reviewer
found the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc and Monovisc. The
documentation does not show that these drugs would likely be less effective and/or have adverse effects for the
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 Euflexxa have not been met. Therefore, we decided that the Plan does not have
to pre-approve use of Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and x-ray provided by an out-of-network provider on September 29, 2020.
You asked the Plan to pay for the office visit and x-ray. You say that the treatment provided was medically necessary and the medical records justify the reason for the services. You say that any policy provision should be waived and the denial should be overturned. The Plan denied your request. The Plan says non-emergent services were provided without authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit and x-ray provided by an out-of-network provider on September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve blocks.

You asked the Plan to pre-approve genicular nerve blocks. The Plan denied your request. The Plan says this is not medically necessary.

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 genicular nerve blocks. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this is an experimental/investigational approach to this problem. It is the subject of ongoing clinical trials. Therefore, the request is considered 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 genicular nerve blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve blocks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (PCD E0651) with appliance provided on October 28, 2020.
You asked the Plan to pay for PCD with appliance. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these items is correct, because the records do not sufficiently support the medical necessity for this PCD.
The Plan follows Medicare rules. Medicare rules state that a PCD is only covered if certain clinical criteria are met, and a PCD related appliance is only covered if the base PCD is 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 PCD with appliance. Our reviewer says that this PCD does not meet the Medicare criteria for coverage. Our physician reviewer found in this case; the order form indicates the presence of chronic venous stasis ulcers. However, the medical records provided do not support this diagnosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PCD with appliance have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (PCD E0651) with appliance provided on October 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on September 18, 2020.
You asked the Plan to waive the copayment for arthrocentesis. You say that you feel that the procedure should not be considered an outpatient surgical procedure. 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 $395 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received arthrocentesis at an outpatient hospital facility on September 18, 2020. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $239.25, which is less than the $395 copayment. You have been asked to pay $239.25 for arthrocentesis. Arthrocentesis falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 arthrocentesis provided on September 18, 2020.