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

 We decided that the Plan does not have to waive the copayment for an ambulance trip to an out-of-network hospital on November 26, 2020.  You asked the Plan to waive the copayment for ambulance services. You say that you began experiencing irregular heartbeat with elevated pulse and blood pressure and shortness of breath. You say you contacted the dispatch unit but due to your condition, you were advised to call 911 and go to the emergency room, to which your cardiologist agreed. You state that upon arrival to the emergency room, you were in atrial fibrillation. You say three of your doctors told you the services would be fully covered, despite being out-of-network, because it was a life-threatening emergency. You request that the Plan waives the copayment since you did not have a choice in which hospital you were taken to. The Plan denied your request. The Plan says a copayment applies if services are rendered, whether or not they are emergent. The Plan says the cost-share was applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $180 copayment for Ambulance Services.    You have been asked to pay a $180 copayment for ambulance services, which applies to the corresponding 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 an ambulance trip to an out-of-network hospital on November 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory testing coded 81226, 81225, 81241, 81240, 81230, and 81291 provided on January 20, 2021.  You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.  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 codes 81226, 81225, 81241, 81240, 81230, and 81291 are not supported in the medical record. Specifically, the services should be coded with code 81479 (used for the entire bundled multi-test panel) in addition to the approved DEX-Z code entered adjacent in the comment/narrative field for the test. Review of the file shows that the services were unbundled to separate codes. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing coded 81226, 81225, 81241, 81240, 81230, and 81291 provided on January 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a low-grade thermal radiofrequency ablation (RFA).  You asked the Plan to pre-approve a low grade thermal RFA. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and necessary when specific criteria are met.  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 low grade thermal RFA. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is a clearly another source of his pain, i.e., the disc protrusion which has not been addressed by a surgical intervention. Only traditional RFA is considered to meet criteria. Therefore, the request is deemed not medically reasonable or 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 a low grade thermal RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve a low-grade thermal radiofrequency ablation (RFA).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency transport (A0427), and ground mileage (A0425) provided on June 20, 2020.  You asked the Plan to pay for the ambulance service. You say that the transport was not related to the enrollee's hospice diagnosis. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency transport (A0427), and ground mileage (A0425) provided on June 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prefabricated abutment (D6056) and abutment supported porcelain/ceramic crown (D6058) provided on December 7, 2020, and December 30, 2020.  You asked the Plan to pay for the prefabricated abutment and abutment supported porcelain/ceramic crown. You say that the Plan's supplemental benefits only state that crowns are covered at 70%. You also say that it does not explain the definitions of which crowns qualify for coverage, and you believe this service should be covered at 30% by the Plan. The Plan denied your request. The Plan says these implant services are not covered benefits under your plan. 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 prefabricated abutment (D6056) and abutment supported porcelain/ceramic crown (D6058) provided on December 7, 2020, and December 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve therapeutic, prophylactic, and diagnostic injections and infusions to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve therapeutic, prophylactic, and diagnostic injections and infusions to be provided by an OON provider. 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 these services. Therefore, coverage criteria have 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 therapeutic, prophylactic, and diagnostic injections and infusions to be provided 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 initial observation care, per day (99220) rendered by the out-of-network (OON) provider on November 5, 2020.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 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 this service. Therefore, we decided that the Plan does not have to pay for the initial observation care, per day (99220) rendered by the out-of-network (OON) provider on November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on April 12, 2021.  You asked the Plan to pay for the dental service. You say that there is only 1 in network dentist in your county. You say that the dental office was short handed at your first appointment, so you do not see the hygienist. You say that your appointment was rescheduled multiple times. You also say that the next closest dentist is over an hour away. The Plan denied your request. The Plan says the complete series x-ray 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 complete series x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on April 12, 2021.   Your complaint about the dental office being short staffed and rescheduling your appointments 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with a surgeon on July 22, 2021.

You asked the Plan to waive the copayment for the visit with a surgeon. You say that this was a follow-up visit from your breast reconstruction surgery, so there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for specialist visits. 

You have been asked to pay a $40 copayment for the visit with a surgeon. Medicare rules state that follow-up visits are only included in the cost of the surgery during the postoperative period. This postoperative period cannot last more than 90 days. Records show that you had surgery on April 12, 2021. The follow-up visit occurred on July 22, 2021, which is 101 days after your surgery. This means that the postoperative period had ended, so any follow-up visits after 90 days post-surgery would have an applicable copayment. 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 visit you had with a surgeon on July 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0676).  You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient services provided on March 31, 2021.  You asked the Plan to pay for outpatient services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.  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 outpatient services provided on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336, 99337) tangential skin biopsy (11102) provided on May 12, 2021 to June 9, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the home visit services. You say that attached are the medical records which will show the medical necessity for these claims. 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, 99337) tangential skin biopsy (11102) provided on May 12, 2021 to June 9, 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 complete series x-ray (D0210) provided on May 27, 2021.  You asked the Plan to pay for the dental service. You say that Medicaid should pick up the balance if your plan does not pay for this service. The Plan denied your request. The Plan says the complete series x-ray 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 complete series x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) genomic sequencing panel provided on April 14, 2021, billed with code 81455.

You asked the Plan to pay for the F1Heme panel. You say that this testing is covered by Medicare and should be paid. The Plan denied your request. The Plan says this is not a covered test.

The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to support the medical necessity of Genomic Sequential Analyses panels for patients with CML for a limited number of individual biomarkers. Panels which test the covered biomarkers and are described by code 81450 may be covered by Medicare. 

We looked at the file and Medicare rules. Review of the information in the file shows that this panel includes analysis of over 50 genes. The billed code 81455 is defined as targeted genomic sequencing with analysis for 51 or more genes. Although some of these genes may be considered medically necessary based on the rules, the entire panel exceeds what is covered under these provisions. Therefore, we decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) genomic sequencing panel provided on April 14, 2021, billed with code 81455.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical assistant services provided during a laparoscopic hernia repair by a Registered Nurse First Assistant (RNFA) on February 12, 2021.  You asked the Plan to pay for the surgical assistant services. You say that this was medically necessary assistance which should be reimbursed. The Plan denied your request. The Plan says this provider is not eligible to be paid for these services.  The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.  In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the surgical assistant services provided during a laparoscopic hernia repair by a Registered Nurse First Assistant (RNFA) on February 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a CT scan of the abdomen (74170).  You asked the Plan to pre-approve a CT scan of the abdomen. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested service have not been met.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 a CT scan of the abdomen. Our reviewer says that the requested service is not medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that the enrollee had a CT of the abdomen in July 2020 that did not demonstrate any liver lesions and an ultrasound in March 2021 that also did not show a lesion. The record does not demonstrate an elevated alpha feto protein or that the ultrasound was inadequate.  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 CT scan of the abdomen have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the abdomen (74170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair.  You asked the Plan to pre-approve the power wheelchair. You say that you require the power wheelchair. The Plan denied your request. The Plan says the documentation reflects that you are able to self-propel in a manual wheelchair.  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.   The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 We decided that the Plan has to partially pay for physical therapy services. We decided that the Plan does not have to pay for all of the physical therapy services.   You asked the Plan to pay for physical therapy services. You say that you do not agree with these charges. The Plan says that these services have been correctly denied.    We decided that the Plan has to pay 65% of the allowed amount for physical therapy services.   The file shows that you have a medical indication for which Medicare will cover 65% of the allowed amount for physical therapy services when received by an out-of-network provider. Therefore, we decided that the Plan has to pay for some physical therapy services.   We also decided that the Plan does not have to pay for all the physical therapy services.  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 45% coinsurance for physical therapy services. The total allowed amount is $231.15. The total amount you are being asked to pay is $104.02 ($231.15 x 45% = $104.02). Therefore, we decided that the Plan does not have to pay for physical therapy services.  If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.