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

 We decided that the Plan does not have to pre-approve an oxygen delivery system.  You asked the Plan to pre-approve an oxygen delivery system. 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 ventilators (E0465, E0466, and E0467) are covered 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 an oxygen delivery system. Our reviewer says that the services are not medically necessary. Our physician reviewer found the provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The record does not indicate that the enrollee trialed a bilevel positive airway pressure (BiPAP) machine or has failed such a device. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.  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 oxygen delivery system have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen delivery system.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychiatric diagnostic evaluation (90792) provided on May 11, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the outpatient services. You say that you have received a denial and you would like to appeal. 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 psychiatric diagnostic evaluation (90792) provided on May 11, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy provided on August 11, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the psychotherapy. You say that you are satisfied with your treatment and do not want to change to another provider. The Plan denied your request. The Plan says no prior authorization was 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 the psychotherapy provided on August 11, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the arthrocentesis and methylprednisolone injections provided on May 10, 2021.  You asked the Plan to pay for the arthrocentesis and methylprednisolone injections. You say that the patient came in for injections of the knee and the claims were only partially paid. You say that the medical records should be reviewed, and the claim considered for payment. The Plan denied your request. The Plan says the records do not support the service 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, the CPT Code Manual definition of code 20611 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting. The CPT Code Manual definition of code J2920 is injection, methylprednisolone sodium succinate, up to 40 mg  We asked our coder 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 arthrocentesis and methylprednisolone injections. Our reviewer says that the documentation does not meet the criteria for reimbursement. Our reviewer found that the medical records provided do not include sufficient documentation to validate that 20611 and J2920 were performed May 10,2021  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the arthrocentesis and methylprednisolone injections have not been met. Therefore, we decided that the Plan does not have to pay for the arthrocentesis and methylprednisolone injections provided on May 10, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for Cinacalcet coded as J0604-AX and unlisted dialysis procedure coded as 90999 provided from January 2, 2021, to June 30, 2021.  You asked the Plan to pay for codes J0604-AX and 90999. 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, the CPT Code Manual definition of code J0604 is Cinacalcet, oral, 1 mg (for ESRD on dialysis). The definition of code 90999 is Unlisted dialysis procedure, inpatient or outpatient.  We find that CPT codes J0604-AX and 90999 are not supported in the medical record. Specifically, J0604 was billed with a modifier no longer payable by Medicare as of January 1, 2021. As a result, the associated dialysis services associated with this drug administration will also be denied. Therefore, we decided that the Plan does not have to pay for Cinacalcet coded as J0604-AX and unlisted dialysis procedure coded as 90999 provided from January 2, 2021, to June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on July 9, 2021.  You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 must 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 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 out of network medical services provided to the enrollee on July 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Daliresp.  You asked the Plan to pre-approve Daliresp. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  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 pre-approve Daliresp.   Benefits for Daliresp 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve gastric peroral endoscopic myotomy (G-POEM) procedure.  You asked the Plan to pre-approve G-POEM procedure. You say that the enrollee underwent G-POEM evaluation and is felt to be a good candidate given her lack of other options for refractory gastroparesis. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that this service is helpful for treatment of gastroparesis.  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 G-POEM procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found medical literature sources agree that G-POEM is still a novel technique that - while promising - is not a standard of care. In this case, the enrollee's poor response to both botox and gastric stimulator may predict her limited clinical success to G-POEM.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of G-POEM procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve gastric peroral endoscopic myotomy (G-POEM) procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the digital hearing aids (V5261) purchased on June 15, 2021, from an out-of-network provider.  You asked the Plan to pay for the hearing aids. You say that these hearing aids are medically necessary, and you understood that your Plan would cover a portion of the cost. The Plan denied your request. The Plan says for hearing aids to be covered by the Plan, they must be purchased through the Plan's routine hearing vendor as specified in the contract. The hearing aids in this case were not purchased through this vendor. Therefore, payment will not be made.  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 for hearing aids only when they are purchased through the Plan's specified hearing vendor network.   We looked at the 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. Therefore, we decided that the Plan does not have to pay for the digital hearing aids (V5261) purchased on June 15, 2021, from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for chiropractic electrical stimulation (G0283) provided on December 2, 2020.  You asked the Plan to pay for chiropractic electrical stimulation. You say that this should be covered. The Plan denied your request. The Plan says this is excluded from coverage.  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 chiropractic electrical stimulation (G0283) provided on December 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an electrocardiogram provided on May 21, 2021.  You asked the Plan to waive the copayment for an electrocardiogram. You say that nothing in the Explanation of Benefits lists any way you would owe this copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for diagnostic tests other than bone mass measurement, colonoscopy, and mammography diagnostic tests.   You have been asked to pay $15.91, which is less than the $50 copayment for an electrocardiogram. Electrocardiograms fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an electrocardiogram provided on May 21, 2021.   Your complaint about not being able to get an explanation from customer service 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 reduce the cost sharing for visits you had with an out-of-network orthopedic specialist from May 18, 2021, to June 21, 2021.  You asked the Plan to reduce the cost sharing for the out-of-network specialist visits. You say that you called the Plan for a provider and they gave you the name of these providers.  You also stated that these providers told you that they were in-network. The Plan denied your request. The Plan says the enrollee was charged the out-of-network copayments correctly.  The Plan says that there are no phone records showing that the enrollee called in and was provided with the names of these non-plan providers.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $55 copayment per visit for out-of-network specialist services.   The enrollee has been asked to pay a $55 copayment per visit for the out-of-network specialist visits. The Plan has confirmed that these providers are out-of-network with the enrollee's Plan, and there is no evidence that the Plan referred the enrollee to these providers.  The Plan cannot be held responsible for incorrect information that may have been given to you by an out-of-network provider.  This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce the cost sharing for visits you had with an out-of-network orthopedic specialist from May 18, 2021, to June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the eyewear purchased on June 24, 2021.  You asked the Plan to pay more for the eyewear. You say that you wanted lenses mounted to your frames but were advised to have new frames. You say that you agreed to have new glasses if it was under $250. The Plan denied your request. The Plan says your frame allowance has been exhausted.   Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $250 every calendar year for eyewear to correct vision.  We looked at the file and the Plan's rules. Specifically, the Plan paid the maximum allowance of $250 for the eyewear purchased on June 24, 2021. You are responsible for the remaining amount. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay more for the eyewear purchased on June 24, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for outpatient mental health telehealth visits you had from June 1, 2021, to August 23, 2021.  You asked the Plan to waive the copayments for the outpatient mental health visits. You say that you received a pamphlet that said that telehealth visits had no copayment. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that copayments were reinstated for all telehealth and behavioral health services effective June 1, 2021.  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 per visit for outpatient mental health services.   You have been asked to pay a $40 copayment per visit for the outpatient mental health visits. Please note that your Plan's website explicitly states that the cost sharing waiver was lifted for Medicare Advantage enrollees effective June 1, 2021. 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 copayments for outpatient mental health telehealth visits you had from June 1, 2021, to August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for vision care services you received on June 4, 2021.  You asked the Plan to waive the deductible for the vision care services. You say that this should be covered by your plan. The Plan denied your request. The Plan says you had not yet met the deductible at the time of these services.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $198 deductible which applies to vision care services.   The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible which applies to vision care services. This cost sharing is a contractual obligation that had not been met at the time the vision care services were received on June 4, 2021. Therefore, we decided that the Plan does not have to waive the deductible for vision care services you received on June 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital care provided from February 1, 2021, through February 5, 2021.  You asked the Plan to pay for inpatient hospital care. The Plan denied your request. The Plan says that enrollees must use in network providers to get medical care and services. The only exceptions are emergencies, urgently needed care, when the network is not available, out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.  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 inpatient hospital care provided from February 1, 2021, through February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for 100 units of morphine (J2274) provided on March 23, 2021.  You asked the Plan to pay for 100 units of morphine. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the records do not support the billing of 100 units of morphine provided on March 23, 2021.  The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.          We find that 100 units of CPT code J2274 are not supported in the medical record. The medical record only supports 2 units of CPT code J2274. Based on this information, we decided that Medicare rules for coverage of 100 units of morphine have not been met. Therefore, we decided that the Plan does not have to pay for 100 units of morphine (J2274) provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cardiology services provided on March 30, 2021, by an OON provider.  You asked the Plan to pay for the cardiology 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 cardiology services provided on March 30, 2021, by an OON provider.