Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transportation and lodging services (A0140, S9975, 99199, A0425) provided on June 15, 2021, through July 7, 2021.  You asked the Plan to pay for the transportation and lodging services. You say that you would like reconsideration because you had to travel in order to receive open heart surgery. The Plan denied your request. The Plan says the transportation and lodging are not a Medicare covered benefit.  The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation and lodging services have not been met. Specifically, Medicare and the Plan only cover transportation and lodging when you receive an organ transplant at a distant location. The records do not indicate that you received an organ transplant.   This service is not a covered benefit under Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the transportation and lodging services (A0140, S9975, 99199, A0425) provided on  June 15, 2021, through July 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a knee brace (L1851) and suspension sleeve (L2397) provided on September 29, 2021.  

You asked the Plan to pay for a knee brace and suspension sleeve. You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met.  

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in the patient's medical record adequately supports the medical necessity for the item.   

The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The provided medical records do not discuss the supplies at issue. Therefore, we decided that the Plan does not have to pay for a knee brace (L1851) and suspension sleeve (L2397) provided on September 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copay for the diagnostic testing provided on December 5, 2020.  You asked the Plan to waive the copay for the services provided. You say that you were told you would be responsible for $90. The Plan denied your request. The Plan says the copays were 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 $110 copay for each Medicare-covered radiological diagnostic service.   The file shows that you received a transthoracic echocardiography and a duplex scan of extracranial arteries. You were charged a $110 copay for each test. You also received myocardial imaging. You were charged $91.35 for this test. Because the amount is less than the $110 copay, you were charged the lesser amount. The services fall within the outpatient diagnostic tests 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 copay for the diagnostic testing provided on December 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a fluid circulating cold pad (E0218) and a pump for water circulating pad (E0236) provided on May 24, 2021.  

You asked the Plan to pay for a fluid circulating cold pad and a pump for water circulating pad. You say that the Plan said to you that they would pay for 80% of the medically necessary items at issue. The Plan denied your request. The Plan says rules for payment have not been met.  

The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad and a pump for water circulating pad are not medically necessary. Based on this information, we decided that Medicare rules for coverage of a fluid circulating cold pad and a pump for water circulating pad have not been met. Therefore, we decided that the Plan does not have to pay for a fluid circulating cold pad (E0218) and a pump for water circulating pad (E0236) provided on May 24, 2021.   

Your complaint about receiving erroneous or incomplete information about your benefits from a representative of the Plan 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (80307, G0480) provided on August 30, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for drug testing. You say that you were not aware of the requirement of obtaining a prior authorization, specifically for this member's Plan at the time of rendering services. You also say that you conducted in good faith the laboratory testing ordered by the referring provider, who deemed the services to be medically necessary. The Plan denied your request. The Plan says this provider is a non-participating provider and the referring provider involved in these services is also non-participating. The Plan also says that prior authorization was not obtained by the provider.  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 drug testing (80307, G0480) provided on August 30, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided from June 26, 2021, to July 25, 2021.  You asked the Plan to pay for the SNF stay. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive skilled service on the dates of service in this case.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF stay. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.  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 SNF stay have not been met. Specifically, the file shows that the enrollee did not receive daily skilled services during the dates of service in this case. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided from June 26, 2021, to July 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayments for the medical eye exams and the intravitreal injection provided from July 31, 2021, to August 31, 2021.  

You asked the Plan to reduce the copayments for the medical eye exams and the intravitreal injection. You say that a Plan customer service representative advised you that you had a $10 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 $20 copayment for each in-network Medicare-covered exam.   

You have been asked to pay a $20 copayment for each of the medical eye exams and the intravitreal injection. The medical eye exams and the intravitreal injection fall within the "Vision Care" benefit category. The record shows a diagnosis of retinal vascular occlusion which makes the visits medical in nature. 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 reduce the copayments for the medical eye exams and the intravitreal injection provided from July 31, 2021, to August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided September 14, 2021.  

You asked the Plan to pay for the periapical x-rays. You say that you were not told you were getting high-priced x-rays. The Plan denied your request. The Plan says that these x-rays are not covered under your benefits. 

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 intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an additional unit of endoscopic catheterization of the biliary ductal system (74328) provided on July 27, 2021.  You asked the Plan to pay for an additional unit of endoscopic catheterization of the biliary ductal system. You say that you would like this claim reprocessed and an additional payment be made for the services rendered. The Plan denied your request. The Plan says no additional documentation supports an additional billed unit of 74328.  The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  We looked at the file and Medicare rules. Without medical records, it is impossible to corroborate if an additional unit of 74328 was performed beyond what the Plan paid for. Based on this information, we decided that Medicare rules for coverage of an additional unit of endoscopic catheterization of the biliary ductal system have not been met. Therefore, we decided that the Plan does not have to pay for an additional unit of endoscopic catheterization of the biliary ductal system (74328) provided on July 27, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Feraheme.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.  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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia and a history of gastric bypass surgery. She has not tried and failed the Plan's required drugs, Ferrlecit, INFeD, or Venofer. The records do not show that the required drugs would be contraindicated or less effective; therefore, the Ferahereme is not reasonable or medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the electrical stimulation (G0283) outpatient office visit (99202) therapeutic massage therapy (97124) provided June 14, 2021.  You asked the Plan to pay for the chiropractic services. You say that the treatment provided by the chiropractors have been the only therapies that have maintained your activities of daily living, ability to work and avoid costly hospitalizations and/or surgery. 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 the electrical stimulation (G0283) outpatient office visit (99202) therapeutic massage therapy (97124) provided June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for electrical stimulation and therapeutic injections/procedures (99212-25, 97032-GP, 97112-GP, J3490-KP, J3411, J3415, J3490-59, J1955-59) provided October 15, 2020.  You asked the Plan to pay for electrical stimulation and therapeutic injections/procedures. You say that the services provided were medically necessary. The Plan denied your request. The Plan says these services are not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services by an NP or PA only when that NP/PA may perform physical therapy services under State law. The rules also say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. The rules also say that Prolotherapy is not a covered benefit.  We looked at the file and Medicare rules. Based on a review of the file and publicly available records, we find that the physical therapy services at issue were rendered by a NP/PA who is not licensed to provide physical therapy in the State of Oklahoma. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Prolotherapy is not a covered benefit of Medicare or the Plan. Based on this information, we decided that Medicare rules for coverage of electrical stimulation and therapeutic injections/procedures have not been met. Therefore, we decided that the Plan does not have to pay for electrical stimulation and therapeutic injections/procedures (99212-25, 97032-GP, 97112-GP, J3490-KP, J3411, J3415, J3490-59, J1955-59) provided October 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 21, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for assistant surgery services for the total knee arthroplasty (27447) provided on July 1, 2021.  

You asked the Plan to pay for the assistant surgery services for the total knee arthroplasty (27447). You say that the medical records should be reviewed for payment of this claim. The Plan denied your request. The Plan says services of a surgical technician assisting at surgery are included in the reimbursement to the facility and not separately reimbursable.  

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 assistant surgery services for the total knee arthroplasty (27447) provided on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a domiciliary or rest home visit (99326) provided on August 5, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a domiciliary or rest home visit. You say that the rendering physician depends upon the hospital staff to verify eligibility and to obtain the proper authorization for the patient's insurance company. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have 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 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 domiciliary or rest home visit (99326) provided on August 5, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a brand specific nebulizer.

You asked the Plan to pre-approve a brand specific nebulizer. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says your records do not show why other available (preferred) alternatives would not be sufficient for your use, or why the brand specific nebulizer is medically necessary.

The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers for durable medical equipment and supplies. 

We looked at the file, the Plan's contract and Medicare rules. The service at issue is a nebulizer from a non-preferred brand. The services are available from the Plan's preferred brands. Therefore, we decided that the Plan does not have to pre-approve a brand specific nebulizer.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit (99214) provided on July 16, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered as they would cause a financial hardship. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for Physician/Practitioner services, including doctor's office visits.    You have been asked to pay a $45 copayment for a specialist office visit. The record indicates that the rendering provider was a hematology & oncology specialist. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit (99214) provided on July 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a root canal (D3320) for tooth # 13.  You asked the Plan to pre-approve a root canal. You say that the service is medically necessary. The Plan denied your request. The Plan says root canal is not 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 requested root canal is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a root canal (D3320) for tooth # 13.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an additional month using a negative pressure wound therapy (NPWT) electrical pump (E2402).  You asked the Plan to pre-approve an additional month using a NPWT electrical pump. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee has been using a NPWT electrical pump for over 4 months. Medicare only covers the use of this item for up to 4 months.  The Plan must follow Medicare rules. Medicare rules say that negative pressure wound therapy pumps are covered for up to four months.  The file shows that treatment has lasted for four months at this point. This pump cannot be covered past four months of use. Based on this information, we decided that Medicare rules for coverage of an additional month using a NPWT electrical pump have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional month using a negative pressure wound therapy (NPWT) electrical pump (E2402).