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

 We decided that the Plan does not have to pre-approve an office visit to be rendered by an out-of-network (OON) provider.  You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.  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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office visit to be rendered by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for core buildup provided on June 23, 2021.  You asked the Plan to pay for core buildup. You say that your tooth had extensive decay and a simple restoration was not possible. You say that you are delaying care might have resulted in complications and you want to know why the claim was denied. The Plan denied your request. The Plan says the service is not a covered benefit.  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 core buildup provided on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on May 27, 2021.  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 testing is not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. The file shows that the testing was done for a diagnosis of Z31.5 (encounter for procreative genetic counseling). Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for Sanexas treatment.  You asked the Plan to pay for Sanexas treatment. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that Medicare pays for outpatient physical therapy services only if they are furnished by or under the supervision of a physical therapist in private practice; or by, or incident to the services of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical services under state law. Medicare rules say that compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.   We looked at the file and Medicare rules. Review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Oklahoma. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code, J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code also cannot be paid. Based on this information, we decided that Medicare rules for coverage of Sanexas treatment have not been met. Therefore, we decided that the Plan does not have to pay for Sanexas treatment.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic testing coded 81479 provided on June 3, 2021.

You asked the Plan to pay for the GeneSight Psychotropic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code 81479 is not supported in the medical record. Specifically, the required DEX Z-code identifier was not billed on the claim. Based on this information, we decided that Medicare rules for coverage of the GeneSight Psychotropic testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic testing coded 81479 provided on June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair with leg supports (K0001, K0195).

You asked the Plan to pre-approve the manual wheelchair. You say that you require the manual wheelchair. The Plan denied your request. The Plan says there was no home assessment to show that the enrollee's home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.

The Plan must follow Medicare rules. Medicare rules say that the documentation must reflect that the enrollee has met Medicare rules for coverage. In this case, to meet coverage for a manual wheelchair, the enrollee's home must provide adequate access between rooms, maneuvering space, and surfaces. There is no evidence of a home assessment in the documentation to show this criterion has been met. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair with leg supports (K0001, K0195).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on July 21, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the home visit services. You say that attached is the medical records, which will show medical necessity for this claim. Please review the requested medical records for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 domiciliary or rest home visit (99336) provided on July 21, 2021 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 power seat elevator (E2300) and expandable controller (E2377, E2311, E2313) for a power wheelchair.  You asked the Plan to pre-approve the power seat elevator and expandable controller. You say that the items are medically necessary. The Plan denied your request. The Plan says coverage criteria for these features has not been met.  The Plan follows Medicare rules. Medicare rules say that power seat elevators are non-covered. Expandable controllers are covered when medically necessary.  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 power seat elevator and expandable controller. Our reviewer says that the requested features are not medically necessary. Our physician reviewer found the seat elevator feature is non-covered under Medicare rules. The records show the enrollee has wrist and digit range of motion within normal limits and that he performs his own self-care and mobility related activities of daily living, thus indicating that he has adequate upper extremity strength and function to control the wheelchair's power options with their own switches. The expandable controller is not medically 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 the power seat elevator and expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevator (E2300) and expandable controller (E2377, E2311, E2313) for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chiropractic services provided on March 31, 2021, to April 5, 2021, by an OON provider.  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 services were rendered by an out-of-network provider without 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 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 chiropractic services provided on March 31, 2021, to April 5, 2021, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a colonoscopy provided on April 30, 2021.  You asked the Plan to waive the copayment for a colonoscopy. You say that you did not want to do the second colonoscopy. You feel that you should not be charged a copayment just because you received the second colonoscopy within months instead of years of the first colonoscopy. 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 $325 copayment for outpatient surgery, including services provided at hospital outpatient facilities.   The medical records show that you had polyps removed during a colonoscopy on April 30, 2021. Therefore, the colonoscopy is considered diagnostic, not preventative. Furthermore, the record shows that you had a colonoscopy screening on January 4, 2021. Therefore, the colorectal cancer screening benefit was exhausted prior to you receiving the services and you are responsible to pay the $325 copayment.   You have been asked to pay a $325 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including 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 a colonoscopy provided on April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency room services (99283) provided on March 26, 2021.  You asked the Plan to waive the copayment for emergency room services. You say that the services should be covered as you were not given consistent information from the Plan. The Plan denied your request. The Plan says the copayment applied correctly based on the service provided.  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 $120 copayment for Emergency care.     You have been asked to pay a $77.60 copayment for emergency room services which is less than the $120 stated in the Plan's contract. Emergency room services fall 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 emergency room services (99283) provided on  March 26, 2021.   Your complaint about the Plan's inconsistency 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.  You asked the Plan to pre-approve SNF services. You say that the member needs continued care and is nearly 100 percent dependent on others. The Plan denied your request. The Plan says that the enrollee is receiving adequate and necessary intensive rehabilitation in the Inpatient Rehabilitation Facility.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the betadine solution povidone provided in an outpatient setting on August 3, 2021.  You asked the Plan to pay for the self-administered drug. You say that you had an appointment for a biopsy. You say that the medication was denied. You say that you cannot remember what medication you received. You also say that you needed it, or it would not have been given to you. The Plan denied your request.  The Plan says Medicare Part B generally does not pay for self-administered drugs used in the hospital outpatient setting. The Plan also says that you may be billed for self-administered drugs that are not covered by Medicare Part B while in a hospital outpatient setting.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the betadine solution povidone provided in an outpatient setting on August 3, 2021.   Benefits for the self-administered drug 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance service (A0429) provided on December 24, 2020.  You asked the Plan to pay for the ground mileage and emergency ambulance service. You say that your insurance should cover this service, or at least cover part of it. The Plan denied your request. The Plan says these services are not payable by Medicare. The Plan also says that you were not bed bound or unable to sit upright, and you were not in pain or behaviorally disturbed.  Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules.   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 the ground mileage and emergency ambulance service. Our reviewer says that the elements of the coverage criteria are not satisfied. Our physician reviewer found the record indicates that your family called the emergency ambulance while you were resident in a nursing home. Our reviewer found that you were at baseline and documents that Advanced Life Support (ALS) transport was not required. A prudent layperson would not have called 911. Our physician reviewer also found that the record indicates that you could have been transported at a lower level of service, such as stretcher van.  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 ground mileage and emergency ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance service (A0429) provided on December 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on July 26, 2021.  You asked the Plan to pay for the periodontal maintenance. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.  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 periodontal maintenance (D4910) provided on July 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance transport rendered on August 31, 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 the claim was not processed by the primary insurer.  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed that an Explanation of Benefits (EOB) has not been received by the primary insurer for this claim. As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the ambulance transport rendered on August 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a ViviGen allograft (20930).  You asked the Plan to pre-approve a ViviGen allograft. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/investigational.  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 a ViviGen allograft. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that ViviGen allograft remains experimental. More research is needed to show safety and efficacy of the ViviGen allograft when used as bone graft in spinal surgery.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a ViviGen allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve a ViviGen allograft (20930).