Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance transportation provided on March 13,
2021.
You asked the Plan to pay for the air ambulance transportation. You say that this was denied as not covered by
Medicare. This is a Medicare-covered transport and was medically necessary. The Plan denied your request.
The Plan says on appeal review, it was determined that the enrollee was under a Medicare hospice election on
the date of service at issue. As such, these services are not payable by the Plan, and should be billed to Original
Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on March 13, 2021. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the air ambulance
transportation provided on March 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 laboratory services provided on June 1, 2021 by an out-of-network (OON) provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for a single-photon emission computed tomography (SPECT) test, echocardiogram, and injection of regadenoson provided on March 10, 2021.
You asked the Plan to waive the cost-sharing for SPECT test, echocardiogram, and injection. You say that it is your understanding that your copayment is $30 and the provider did not mention any additional charges. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.
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 $100 copayment for SPECT test, $25 copayment for echocardiogram, and 20% coinsurance for injection. The allowed amount of the injection is $225.61, resulting in a coinsurance amount of $45.12. Your total cost-sharing amount is therefore $170.12.
You have been asked to pay $100 copayment for SPECT test, $25 copayment for echocardiogram, and 20% coinsurance for injection. SPECT test, echocardiogram, and injection fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" and "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 cost-sharing for a single-photon emission computed tomography (SPECT) test, echocardiogram, and injection of regadenoson provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 14, 2021.

You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says
services rendered by non-participating providers require prior authorization as outlined in the enrollee's
Evidence of Coverage.

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 subsequent nursing facility care provided on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 18, 2021 by an out-of-network (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 laboratory services provided on May 18, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on January 19, 2021.

You asked the Plan to pay for the hearing aids. You say that your audiologist advised that your hearing aids
were failing, and you had to get new devices. You say that you thought your benefit was available every year
and the 12-month requirement should be waived. The Plan denied your request. The Plan says your $2,000
allowance has already been issued.

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 $2,000
toward hearing aids once every 12 months.

We looked at the coverage rules, the case 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. Specifically, the Plan paid $2,000 toward
the hearing aids provided on March 22, 2020, which exhausted your benefit. Therefore, we decided that the
Plan does not have to pay for the hearing aids provided on January 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
You asked the Plan to pre-approve Durolane. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation does not support that the enrollee has tried and failed the Plan's required drugs.
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 looked at the file and Medicare rules. The Plan requires a trial and failure of preferred drugs, Orthovisc or Monovisc before they can approve Durolane for the enrollee. No medical records from you, the enrollee's treating physician were provided to support that the enrollee has tried and failed these required drugs or that the enrollee has a reason that these drugs would be less effective and/or cause adverse effects for the enrollee. The documentation shows that the Plan has requested these medical records on various occasions with no response. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT of the head and brain (70450) provided on June 29,
2021.

You asked the Plan to pay for the CT of the head and brain. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says procedures that represent overlapping
services are considered mutually exclusive.

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, we have confirmed that code 70450
has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate
line item. Of note, this service has not been billed with a modifier to indicate that this is a separate and distinct
procedure. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for the CT of the head and brain (70450) provided on June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown for tooth #4 (D2740).
You asked the Plan to pre-approve a crown for tooth #4. You say that the services are necessary. The Plan denied your request. The Plan says the benefit has been exhausted.
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 one procedure per tooth every five years We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown for tooth #4 have not been met. Specifically, the service was already rendered on this tooth on April 16, 2018. Therefore, we decided that the Plan does not have to pre-approve a crown for tooth #4 (D2740).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services represented by code 71045 provided on May 15, 2021.
You asked the Plan to pay for code 71045. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045 has a bundled relationship with code 71046 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services represented by code 71045 provided on May 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services provided to the enrollee on May 5, 2021.
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 payment is not allowed for these codes.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) codes 36478 and 37765. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid.
Additionally, CPT 37799 was billed, which has a definition of "Unlisted procedure, vascular surgery." There is no description in the case file of what this procedure was supposed to be. The code is not substantiated in the medical records to greatest specificity possible. Based upon this information, we find that Medicare coverage criteria for the services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided to the enrollee on May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor.
You asked the Plan to pay for the continuous glucose monitor. You say that the claim should be paid. The Plan denied your request. The Plan says this was an unsolicited call and the member said they did not want the items.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter.
Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient mental health stay provided by an out-of-network provider on March 2, 2021, to March 22, 2021.
You asked the Plan to pay for an inpatient mental health stay. You say that these services are medically necessary for member. The Plan denied your request. The Plan says the patient did not meet the level of care criteria for an acute inpatient psychiatric hospitalization.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 an inpatient mental health stay. Our reviewer says that the patient was compliant with treatment while not showing any acute threats to safety. Our physician reviewer found this enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations while being cooperative with treatment. 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 inpatient mental health stay have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient mental health stay provided by an out-of-network provider on March 2, 2021, to March 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET scan to be provided by the requested facility.
You asked the Plan to pre-approve a PET scan to be provided by the requested facility. You say that you have been seen at this facility for all your cancer issues and you would like to continue to go there for the PET scan. The Plan denied your request. The Plan says your information does not show that you need the PET to be provided at a tertiary level care facility.
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 PET scan to be provided by the requested facility. Our reviewer says that the PET scan to be provided by the requested facility is not considered medically reasonable and necessary in this case. Our physician reviewer found that a tertiary level of care for the PET scan is not medically necessary at this time. The PET scan be safely performed at a lower level of care, as recommended by the Plan.
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 PET scan to be provided by the requested facility have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET scan to be provided by the requested facility.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on January 13, 2021, to January 15, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you went to the hospital for Coronavirus treatment. You also say that you were released to go home and then developed ulcers and you had to return to the hospital almost two weeks later. You say you should not have a copayment since the treatment caused the return to the hospital. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $295 copayment per day, for days 1-6 for inpatient hospital care. Your contract with the Plan also clearly says that you pay a $0 copayment per day, for days 7-90 for inpatient hospital care. You have been asked to pay a $295 copayment per day for inpatient hospital care. The records show that you received inpatient hospital care for two days and your total cost share is $590 ($295 x 2 days = $590). The EOC confirms $295 per day is the required copayment for this service. 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 inpatient hospital care provided on January 13, 2021, to January 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 28, 2021 by an out-of-network (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 laboratory services provided on April 28, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment with the Sanexas device and subcutaneous injections of a nutria-pharmaceutical blend provided on September 2, 2020.

You asked the Plan to pay for the Sanexas device treatment and associated injections. You say that this is a Food and Drug Administration cleared device which has shown great efficacy in the treatment of chronic pain. This is coded correctly and should not be considered experimental. The Plan denied your request. The Plan says the services rendered are not shown to be medically reasonable and necessary. The use of this device for the enrollee's condition is experimental and not provided within the Medicare covered indications.

The Plan must follow Medicare rules. Medicare rules say that physical therapy services may only be covered when they are provided by an NP when that NP is allowed to perform physical therapy by State law. It is also noted that compounded drugs must be billed using a not otherwise classified code, which is code J7999. The Sanexas treatment provided has been billed using codes 97112, 97032, and 97016. These are "always therapy" codes and were billed with physical therapy modifier GP. 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 who is not licensed to provide physical therapy in the State of Virginia.

The nutria-pharmaceuticals provided were billed with codes J1955, J3411, J3415, J3420, and J3490. 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, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to pay for the treatment with the Sanexas device and subcutaneous injections of a nutria-pharmaceutical blend provided on September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0220), filling (D2331) for tooth # 23,
and filling (D2391) for tooth # 13 provided on May 7, 2021.
You asked the Plan to pay for the dental services. You say that this claim should be covered. You also say that
you were not aware prior to cancelling your optional supplemental dental coverage that you would not be able
to re-enroll later in the plan year as you had been able to do in previous years. The Plan denied your request.
The Plan says there is a $500 maximum benefit for dental services each year. The Plan also says that the
maximum benefit has been exhausted.
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, there is an annual maximum benefit of
$500 per year. The record shows that the Plan paid $150 for an oral evaluation performed on February 23,
2021, $401.50 for a crown performed on February 23, 2021, and $93 for dental services performed on May 19,
2021. $150+$401.50+$93=$644.50. Therefore, we decided that the Plan does not have to pay for the periapical
x-ray (D0220), filling (D2331) for tooth # 23, and filling (D2391) for tooth # 13 provided on May 7, 2021.