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

We decided that the Plan does not have to pay for the medical services provided on January 17, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the OON services. 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 January 17, 2020 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 continuous passive motion (CPM) device. 
 
You asked the Plan to pre-approve a CPM device. You say that the requested item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. 
 
You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to preapprove a continuous passive motion (CPM) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure
device (CPAP) and heated humidifier.
You asked the Plan to pre-approve continued CPAP and humidifier use. The Plan denied your request. The
Plan says that medical necessity criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that you must use the PAP 4 hours per night on 70%
of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage.
We looked at the file and Medicare rules. The file indicates the enrollee did not adhere to therapy. Based on
this information, we decided that Medicare rules for coverage of continued CPAP and humidifier use have not
been met. Therefore, we decided that the Plan does not have to pre-approve continued use of a continuous
positive airway pressure device (CPAP) and heated humidifier.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F5 and F2 genetic testing. You asked the Plan to pre-approve these services. You say that the enrollee needs the testing. The Plan denied your request. The Plan says the testing is not covered. The Plan must follow Medicare rules. Medicare rules say that F5 and F2 genetic testing is not covered. We looked at the file and Medicare rules. The testing at issue is F5 and F2 genetic testing. This testing is not covered by Medicare for any indication. Therefore, we decided that the Plan does not have to pre-approve F5 and F2 genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-sterile gloves (A4927). You asked the Plan to pre-approve the non-sterile gloves. You say that you have had an ileostomy for 10 years and your primary doctor has requested that you wear gloves each time you use the restroom to protect against infections. The Plan denied your request. The Plan says this item is not a covered benefit. 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 non-sterile gloves (A4927).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that not having a portable oxygen concentrator is causing you stress and this is no way to live. The Plan denied your request. The Plan says that you currently have a stationary home oxygen concentrator and portable oxygen tanks for your oxygen needs within the home and are requesting a portable oxygen concentrator for use outside the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve acupuncture services.
You asked the Plan to pre-approve the services. You say that this has given you relief of your chronic low back pain. The Plan denied your request. The Plan says that long-term acupuncture for the treatment of chronic, non-resolving pain conditions is not medically appropriate, and also not covered.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90 period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 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 medically reasonable and necessary. Our physician reviewer found acupuncture services are requested for this 68 year old enrollee for ongoing treatment of chronic low back pain related to lumbar spondylosis and myofascial tender points. It is noted that the enrollee has been receiving acupuncture services through a supplemental Medicare plan - most recently he was approved for 12 visits ending April 16, 2020. The plan states, "acupuncture is not covered by Original Medicare, rather under the Medicare Advantage supplemental benefit. However, per National Coverage Determination (NCD) for ACUPUNCTURE for Chronic Lower Back Pain (cLBP) (30.3.3) effective for dates of services after January 21, 2020, Medicare covers acupuncture for 12 visits per 90 days for treatment of chronic back pain lasting at least 12 weeks, if other criteria are met. The prescribing pain management specialist has documented that with acupuncture treatment, pain level improves from 6 - 7/10 down to about 2-3/10, and functional status improves to significantly limited to able to do anything. A review of the documentation submitted and the NCD for Acupuncture noted above indicates that the criteria for coverage of acupuncture services for 12 visits have been met. Of note, an additional 8 session may be covered if there is documentation of improvement, with a limit of 20 visits per year. 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 been met. Therefore, we decided that the Plan has to pre-approve acupuncture services.
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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary-level referral.
You asked the Plan to pre-approve the referral. You say that you are unable to drive the freeway, and you don't want to contract COVID-19 using transportation services provided by the plan. The Plan denied your request. The Plan says the criteria is not met for a tertiary level provider.
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 referral. Our reviewer says that the requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer found the main issue for you appears to be the driving distance - which is generally considered a matter of convenience, and not of medical necessary. You live close enough to drive yourself, and would not drive expressways, which are the only routes to the in network radiation oncologist. Many cancer centers provide means for lodging or travel, particularly if there was a medical reason that you could not drive. Apparently transportation would be provided. You are concerned about risks of COVID19 exposure with longer travel, which arguably is outside the scope of this type of review though generally transportation services are complying with the need to disinfect between passengers, and with mask wearing and infectious precautions. There are no compelling or plausible medical reasons to support the medical necessity of you receiving radiation treatment out of network. There is no evidence in the case file that the out of network provider would provide a service that an in network provider cannot. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tertiary-level referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a tertiary-level referral.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing to be provided with an out-of-network physician.
You asked the Plan to pre-approve the genetic testing with an out-of-network physician. The Plan denied your request. The Plan says the services can be provided in-network and are not emergent or urgent.
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 genetic testing to be provided with an out-of-network physician.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes G0480 and 80307 provided on September 5, 2019. 
 
You asked the Plan to pay for CPT codes G0480 and 80307. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Medicare says providers should use the diagnosis code for billing that describes the patient's diagnosis, symptom, complaint, condition or problem to the highest level of specificity. In this case, the claim was billed with diagnosis code F14.10. This diagnosis code is not a covered code to be billed with CPT codes G0480 and 80307. Therefore, we decided that the Plan does not have to pay for CPT codes G0480 and 80307 provided on September 5, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (90791, 90837, 90834) provided on January 10, 2020 to March 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient mental health services. You say that the service was medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the outpatient mental health services (90791, 90837, 90834) provided on January 10, 2020 to March 3, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the provided medical records do not indicate a need for daily skilled services or inpatient services. Care in the home or an assisted living facility with home health services appears to be appropriate. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on December 12, 2019.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says that the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 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 psychotherapy services provided on December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the upgrades to the eyeglasses provided on November 5, 2019. You asked the Plan to pay for the upgrades. You say that the provider's office told you the cost of your glasses would be fully covered. The Plan denied your request. The Plan says upgrades are not covered for glasses after cataract surgery. The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for, the progressive lenses, are considered upgrades. The services are not covered for glasses after cataract surgery. Therefore, we decided that the Plan does not have to pay for the upgrades to the eyeglasses provided on November 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay this claim as billed. You asked the Plan to pay for anesthesia services provided to the enrollee. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says after reviewing the claim it has been determined that the claim processed correctly according to the plan benefits however the claim line contains a non-anesthesia service that the American Society of Anesthesiologists has identified as having a one-to-one relationship with a more appropriate anesthesia service code. Payment is not allowed because this claim line records non-anesthesia services submitted by an Anesthesiologist. There is a more appropriate code that should be used for non-anesthesia services provided to the enrollee. 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 claim cannot be paid as billed because there are non-anesthesia services being reported by an anesthesiologist, which are not allowed for Medicare billing purposes. The Plan states the claim must be resubmitted with the appropriate code. Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay the claim submitted for anesthesia services provided to the enrollee on December 17, 2019 as currently billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair, accessories, power seat elevation feature, reclining back option and electronic upgrades.
You asked the Plan to pre-approve a Group 3 power wheelchair, accessories, power seat elevation feature, reclining back option and electronic upgrades. You say that you need the power wheelchair and accessories. The Plan denied your request. The Plan says there is no evidence you are at a high risk for developing a pressure ulcer or unable to perform a functional weight shift. A seat elevation feature is not primarily medical in nature and the electrical connection device is not necessary.
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 Group 3 power wheelchair, accessories, power seat elevation feature, reclining back option and electronic upgrades have not been met. The power options come with their own switches and a power seat elevation feature does not serve a purpose that is primarily medical in nature. There is no past history of ulcers. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair, accessories, power seat elevation feature, reclining back option and electronic upgrades.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the paracentesis provided on February 6,
2020.
You asked the Plan to waive the copayment for the paracentesis. You say that you haven't paid for the
paracentesis before. You say that it is not a surgery. The Plan denied your request. The Plan says the
copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $405
copayment for each covered surgery or surgical procedure performed as an outpatient at an in-network hospital.
You have been asked to pay a $405 copayment for the paracentesis. The paracentesis falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The paracentesis is considered a surgical procedure. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the paracentesis provided on February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased November 4, 2019.
You asked the Plan to pay for the hearing aids. You say that you are appealing the decision to deny payment
for your hearing aid. The Plan denied your request. The Plan says enrollee's must receive hearing aids from a
TruHearing provider.
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 pays for
hearing aids only when provided by a TruHearing provider
We looked the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for
the hearing aids purchased November 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 5, 2020. You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service. The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 5, 2020.