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

We decided that the Plan does not have to pay for critical care services (CPT 99291) provided to the enrollee from August 20, 2019 to August 26, 2019. You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation did not support the billed code, as the records did not include the time spent providing the service. 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 99291 is "critical care visit of 30-74 minutes." We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not contain a note of how long was spent providing this service. As the code is time-based, it cannot be verified as being provided. 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 pay for critical care services (CPT 99291) provided to the enrollee from August 20, 2019 to August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee wrap. You asked the Plan to pre-approve a knee wrap. You say that the knee orthosis you have does not support your knee. The Plan denied your request. The Plan says this item is not covered. The Plan must follow Medicare rules. Medicare rules say that elastic or other fabric support garments with or without stays or panels do not meet the statutory definition of a brace because they are not rigid or semi-rigid devices and are denied as non-covered. We looked at the file and Medicare rules. The record shows that the Plan confirmed with your provider that the device in question is elastic and will not provide support. Based on this information, we decided that Medicare rules for coverage of a knee wrap have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee wrap.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmology services, medical examination and evaluation (92014) and refraction (92015) provided January 6, 2020. You asked the Plan to waive the copayment for the ophthalmology services. You say that this is preventive service and you feel that checking for the cataracts should be part of the routine eye exam and you do not feel you should owe a $45 copayment. The Plan denied your request. The Plan says the claim was processed 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 $45 copayment for outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye. You have been asked to pay $45 copayment for the ophthalmology services. The ophthalmology services fall within the Vision 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 ophthalmology services, medical examination and evaluation (92014) and refraction (92015) provided January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on August 27, 2019. You asked the Plan to waive the deductible for the office visit. You say that this was processed out-of-network without any notification from the Plan. You say that the additional bill is a burden. The Plan denied your request. The Plan says the deductible applied correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The enrollee's contract with the Plan says that the deductible is $500. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Out-of-network services are not excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $500 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the out-of-network office visit was received on August 27, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on August 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 1, 2019. 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 there is no valid physician order. The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered on August 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit package for the enrollee. You asked the Plan to pre-approve a transit package. The Plan denied your request. The Plan says that this is for use outside the home and not covered. 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 transit package for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total knee arthroplasty (27447) to be provided by an out of network (OON) provider. You asked the Plan to pre-approve a total knee arthroplasty. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide this care. Therefore, coverage criteria has not been met. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a total knee arthroplasty (27447) to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered to on December 17, 2019. 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 the claim is a duplicate. The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 pay for the chest x-ray rendered to on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 2, 2019. You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior 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 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 physician's services provided on December 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. You asked the Plan to pre-approve foot orthotics. You say that you need these foot orthotics and will end up in a wheelchair without them. The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for unlisted ambulance service (A0999) provided October 24, 2019. You asked the Plan to pay for the unlisted ambulance service. You say that your records show that you billed with correct codes and is appealing along with the medical records. The Plan denied your request. The Plan says this is not a covered benefit. The Plan must follow Medicare rules. Medicare rules say that payment for this items is included in the transportation fee. Medicare does not allow for separate billing of this service and supplies. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the unlisted ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for unlisted ambulance service (A0999) provided October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management reported on October 2, 2019 with CPT code 99239. You asked the Plan to pay for CPT code 99239. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says CPT code 99239 was paid on a previous claim. The Plan must follow Medicare rules. Medicare rules say that hospital discharge day management is a face-to-face evaluation and management (E/M) service between the attending physician and the patient. Only one hospital discharge day management service is payable per patient per hospital stay. We looked at the file and Medicare rules. We find that, based on the Plan's processing of previous claims, payment for CPT code 99239 is not supported. Specifically, the record shows that CPT code 99239 was submitted and paid on a previous claim. According to Medicare rules, only one hospital discharge day management services is payable per hospital stay. Based on this information, we decided that Medicare rules for coverage of CPT code 99239 have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management reported on October 2, 2019 with CPT code 99239.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gel pressure mattress pad (E0185). You asked the Plan to pre-approve a gel pressure mattress pad. You say that you are not able to reposition yourself due to spinal surgery. The Plan denied your request. The Plan says this item is not medically necessary. The Plan must follow Medicare rules. Medicare rules say that a Group 1 mattress overlay or mattress is covered if the beneficiary is completely immobile or has limited mobility or pressure ulcers. We looked at the file and Medicare rules. The submitted medical records do not show that you have limited mobility or pressure ulcers. Based on this information, we decided that Medicare rules for coverage of a gel pressure mattress pad have not been met. Therefore, we decided that the Plan does not have to pre-approve a gel pressure mattress pad (E0185).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve varicose vein treatment to be provided by an out of network (OON) provider. You asked the Plan to pre-approve varicose vein treatment. You say that you would like approval for these services. The Plan denied your request. The Plan says there are in-network providers available for these services. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve varicose vein treatment to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for hearing aids provided on September 3, 2019. You asked the Plan to waive the coinsurance for hearing aids. You say that there should not be a charge for an out-of-network provider when the Plan had no cost or involvement in this purchase other than reimbursement to you. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct, and you are responsible for any amount above $1,000. 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 25% coinsurance for out-of-network hearing aids. The maximum allowable amount for this Plan benefit is $1,000, resulting in a coinsurance obligation of $250. You are also responsible for any amount paid over $1,000. You have been asked to pay 25% coinsurance for hearing aids, and any amount over $1,000. Hearing aids fall within the Mandatory Supplement Hearing Benefit 833 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 hearing aids provided on September 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a CT scan provided on December 11, 2019. You asked the Plan to pay for the CT scan. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior 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 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 a CT scan provided on December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 18, 2019 by an in network provider. You asked the Plan to pay for the limited oral evaluation. You say that you found the clinic on the provider list for dental care. You say that you called the plan to verify they were contracted. You also say that you feel you have been misled regarding your dental benefits. The Plan denied your request. The Plan says the limited oral evaluation is not listed as a covered service. 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 limited oral evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 18, 2019 by an in network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided by a provider that does not participate in Medicare from August 20, 2019 to September 27, 2019. You asked the Plan to pay for home health services. You say that you were not told that these services needed to be provided by a provider that participates in Medicare. The Plan denied your request. The Plan says services from non-participating providers cannot be paid. The Plan must follow Medicare rules. Medicare rules say that home health services are covered only when the home health agency that is providing the services to the beneficiary has in effect a valid agreement to participate in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. The provider you received these services from does not participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for home health services provided by a provider that does not participate in Medicare from August 20, 2019 to September 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on August 12, 2019. You asked the Plan to waive the copayment for the laboratory work. You say that the laboratory work should have been fully covered as a part of the annual physical. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $35 copayment per day, per provider, for in-network Medicare-covered lab services. You have been asked to pay a $35 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 the laboratory work provided on August 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper partial dentures (D5213) and lower partial dentures (D5214). You asked the Plan to pre-approve upper and lower partial dentures. You say that your old partial dentures are not sufficient and you cannot eat. The Plan denied your request. The Plan says these items are covered only once every five years. 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 upper and lower partial dentures once every five years. We looked at the file and Medicare rules. The record shows that you previously received upper partial dentures (D5213) and lower partial dentures (D5214) in 2017. This means you have received these items within the last five years. Based on this information, we decided that the Plan's rules for coverage of upper and lower partial dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve upper partial dentures (D5213) and lower partial dentures (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 26, 2019 by an out of network (OON) provider. You asked the Plan to pay for physician visit. You say that you are appealing. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 the medical services provided on December 26, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328) for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy encourages enrollees to try the preferred agents, which are just as effective- Monovisc and Orthovisc.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not trialed other viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does outline contraindications or reasons these medications were not considered. Without the support of the documentation, Gelsyn-3 is not approved as step criteria is not met.
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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3 (J7328) for the enrollee.