Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 power scooter.
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says this is being requested for community mobility.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found it is not clear that your mobility deficit impairs MRADLs in the home and is not ameliorated by a manual wheelchair. While you may be able to safely operate a PMD, the requested scooter exceeds your medical need. It does not appear that this will significantly improve your ability to perform MRADLs in the home.
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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 1 power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for special anesthesia service (99100) provided on October 20, 2020.
You asked the Plan to pay for anesthesia. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because payment for this service is always bundled so it is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that payment for code 99100 is always subsumed by the payment for the services to which it is incident. We looked at the file and Medicare rules. Payment for this code is always bundled, so it is not separately payable. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for special anesthesia service (99100) provided on October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for manual therapy techniques (97140) mechanical traction (97012) and electrical stimulation (G0283) provided May 11, 2021.
You asked the Plan to pay for the chiropractic services. You say that on your first visit to the office, the staff took your insurance cards and told you that you may get 25 visits at no charge with your plan. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for manual therapy techniques (97140) mechanical traction (97012) and electrical stimulation (G0283) provided May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a physician visit provided on March 24, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for physician visit. You say that this service was provided with no adequate timeframe to obtain authorization. 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 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 a physician visit provided on March 24, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 4, 2020, by
an out-of-network provider.
You asked the Plan to pay for subsequent nursing facility care (99309). You say that the service was provided
with no adequate time frame to obtain authorization. The Plan denied your request. The Plan says the provider
did not attempt an authorization request for any 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 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 service 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 the service. Therefore, we decided that
the Plan does not have to pay for subsequent nursing facility care provided on June 4, 2020, by an out-of-network
provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology panel testing services (CPT code(s): 81408 and 81479) provided to the enrollee on November 17, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Review of the available clinical case notes and records presented for an appeal of molecular pathology panel testing has been completed. After reassessing the entire situation, the result is that the initial denial is upheld. The enrollee had molecular pathology panel testing on November 17, 2020. The denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Therefore, we decided that the Plan does not have to pay for molecular pathology panel testing services (CPT code(s): 81408 and 81479) provided to the enrollee on November 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator for the enrollee.

You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says medical necessity was not established.

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.

To qualify for home oxygen, the patient must meet one of the following blood gas levels: 

1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 

2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 

3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 

4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.

For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage.

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 concentrator. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found supplemental oxygen is not medically necessary. The enrollee has chronic obstructive pulmonary disease (COPD), and apparently has been on oxygen at night. The record consists of a medical encounter that is undated (fax date 2/22/21), showing oxygen saturation of 93% on room air at rest and 92% walking. This does not meet the criteria of oxygen needs. There is no overnight oximetry. 

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 concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the chiropractic services rendered on March 29, 2021 to May 17, 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 that the services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation when there is an expectation of improvement in function. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states the services are not covered when performed by a chiropractor; however, the file shows that the claims are for procedure code 98942 (chiropractic manipulative treatment (CMT); spinal, 5 regions). These services are Medicare-covered chiropractic manipulation. The Plan has not provided any documentation to support that you received non-covered chiropractic services. Therefore, we decided that the Plan has to pay for the chiropractic services rendered on March 29, 2021 to May 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Leuprolide Acetate injection your
received on June 8, 2021.
You asked the Plan to waive the coinsurance for the Leuprolide Acetate injection. You say that these charges
were reversed in 2020, so you believe you should not be charged for this injection. The Plan denied your
request. The Plan says you were charged this coinsurance correctly. The Plan says that the coinsurance waiver
you receive in 2020 was in error.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare Part B drugs.
You have been asked to pay 20% coinsurance for the Leuprolide Acetate injection. The Leuprolide Acetate
injection falls within the Medicare Part B drugs benefit category. This coinsurance applies regardless of what
you may have paid or not paid in prior years. 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 the
Leuprolide Acetate injection your received on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient nerve conduction testing (95912) provided June 30, 2021.
You asked the Plan to waive the coinsurance for the outpatient services. You say that you should not owe an outpatient procedure coinsurance. The testing was done in the doctor's office and you had paid the $50 specialist copay. The Plan denied your request. The Plan says the claim was processed with the correct cost share applied per the Evidence of Coverage.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance per visit. You have been asked to pay $104.40 ($522.01 (allowed amount) x 20% coinsurance) for the outpatient services. The outpatient services fall 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 coinsurance for the outpatient nerve conduction testing (95912) provided June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit and the Synvisc injection provided on April 26, 2021.
You asked the Plan to waive the copayment for the specialist office and the Synvisc injection. You say that you assumed that since the service was approved in advance that there would be no copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $40 copayment for in-network physician specialist services (including surgery second opinion, telehealth, and urgently needed services) and 20% coinsurance for all other in-network drugs covered under Medicare Part B. You have been asked to pay a $40 copayment for the specialist office visit. You have also been asked to pay $214.58 which is 20% of the allowed amount for the Synvisc injection. The allowed amount is $1,072.90. ($1,072.90 x 20% = $214.58). The specialist office falls within the "Physician/practitioner services, including doctor's office visits" benefit category. The Synvisc injection falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit and the Synvisc injection provided on April 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator (E1390) provided on September 16, 2020, to January 16, 2021.
You asked the Plan to waive the coinsurance for an oxygen concentrator. You say that the charges at issue are for medical supplies that you either own or that have never been delivered. The Plan denied your request. The Plan says the correct coinsurance was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for durable medical equipment.
You have been asked to pay $14.05 per date of service, or 20% of the Medicare-allowed charge of $70.23, for an oxygen concentrator. An oxygen concentrator falls within the "Durable medical equipment (DME) and related 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 coinsurance for an oxygen concentrator (E1390) provided on September 16, 2020, to January 16, 2021.
Your complaint about not receiving items/services from the durable medical equipment supplier 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the pelvic ultrasound (76856) provided on May 1, 2021 by an OON provider.

You asked the Plan to pay for the pelvic ultrasound. You say that you would like this claim to be reconsidered for a retrospective authorization. The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says that there is no referring provider, and prior 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 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 pelvic ultrasound (76856) provided on May 1, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided January 19, 2021.
You asked the Plan to pay for the tooth extraction. You say that you would like the service covered. The Plan denied your request. The Plan says this service is not covered because the provider has opted out of Medicare.
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 the tooth extraction when the services are medically necessary and reasonable. We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the tooth extraction have not been met. Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided January 19, 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 2, 2020 by
an out-of-network provider.
You asked the Plan to pay for subsequent nursing facility care (99309). You say that the service was provided
with no adequate time frame to obtain authorization. The Plan denied your request. The Plan says the provider
did not attempt an authorization request for any 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 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 service 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 the service. Therefore, we decided that
the Plan does not have to pay for subsequent nursing facility care provided on April 2, 2020 by an out-of-network
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for transurethral procedures (including urethrocystoscopy); transurethral resection of bladder tumor(s) (CPT code 00912) provided on November 12, 2020.
You asked the Plan to pay for the service. You say that you are requesting that the Health Plan re-issue payment to the provider in the amount of $257.96. The Plan denied your request. The Plan says your other Health Plan has the primary responsibility for paying this claim.
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 says they would consider your claim upon receipt of the primary insurer's Explanation of Benefits (EOB) for the service in dispute. As the secondary insurer, the Plan cannot be held responsible for the service until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for anesthesia for transurethral procedures (including urethrocystoscopy); transurethral resection of bladder tumor(s) (CPT code 00912) provided on November 12, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Leuprolide Acetate 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 guidelines were not followed.
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 services are not medically reasonable or necessary. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. 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 Leuprolide Acetate for the enrollee.