Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for evaluation and management services provided on June 8, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON evaluation and management services. You say that it is the nursing facility's responsibility to get authorization. The Plan denied your request. The Plan says the services in dispute were provided out of network and were not 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 evaluation and management services provided on June 8, 2021 by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87481) provided May 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that the lab test was medically necessary. The Plan 
denied your request. The Plan says this service is investigational and is not covered. 
 
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 pay for the lab services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. 

Our physician reviewer found Polymerase Chain Reaction (PCR) urine testing techniques raise considerable 
concerns regarding contamination from one specimen to another, creating the potential for false-positive 
results. The clinical interpretation of PCR results may also be challenging. Amplification of organisms 
representing latent infection or colonization cannot be distinguished from active, clinically significant 
infections. This procedure is not the standard of care. 
 
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 lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (87481) provided May 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed (CPT code G0483) provided to the enrollee on May 13, 2021.
You asked the Plan to pay for the testing. You say that the service is medically necessary, and the claim should be paid. The Plan denied your request. The Plan says the medical records only support 18 drug classes. The Plan states they have reprocessed the claim and upheld it as denied due to the item or service does not meet the criteria for the category under which it was billed.
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 testing. Our physician reviewer found the review indicates that the medical records do not contain documentation of definitive laboratory results for 22 or more drug classes, including metabolites to support the coding criteria for G0483 for the billed date of service May 13, 2021. The medical records only support 18 drug classes. The review has determined that the service was not supported by the medical records provided. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug test(s) (Current Procedural Terminology (CPT) code G0483) provided to the enrollee on May 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jardiance tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that the enrollee needs this for her 
condition. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare 
Part D prescription drug benefits. 
 
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 Jardiance tablets.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for (2) dental fillings (D2332, D2330), a comprehensive oral evaluation (D0150) and periodontal scaling and root planing (D4342) provided on May 17, 2021, to June 9, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for dental fillings, comprehensive oral evaluation and periodontal scaling and root planing. You say that you used a non-participating provider because the treatment plan would cost you less. You also say your plan covers 2 fillings, but you had 4 fillings and assumed the $2,000 total annual benefit coverage could be used for the additional fillings. The Plan denied your request. The Plan says you received services from an OON provider. The Plan also says that there is no coverage for periodontal scaling & root planing.

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. 

We looked at the file and Medicare rules. The contract confirms that the $2,000 annual benefit maximum applies to covered services. The records show that you received reimbursement for one comprehensive oral evaluation and two fillings for 2021. The contract also confirms that periodontal scaling and root planning are not a covered benefit with Medicare or the Plan. Based on this information, we decided that the Plan's rules for coverage of dental fillings, a comprehensive oral evaluation and periodontal scaling and root planing have not been met. Therefore, we decided that the Plan does not have to pay for (2) dental fillings (D2332, D2330), a comprehensive oral evaluation (D0150) and periodontal scaling and root planing (D4342) provided on May 17, 2021, to June 9, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) and the electrocardiogram (93000) 
rendered by the out-of-network (OON) provider on March 23, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care, and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the office visit (99203) and the electrocardiogram (93000) rendered by the out-of-
network (OON) provider on March 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on 
November 21, 2019. 
 
You asked the Plan to pay for the therapy services. 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 therapy services provided and billed incident to 
the services of a physician/NPP also must meet all incident-to requirements. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and 
not a licensed therapist. When therapy services are billed as incident to a physician/NPP services, the 
requirement for direct supervision by the physician/NPP and other incident to requirements must be met, even 
though the service is provided by a licensed therapist who may perform the services unsupervised in other 
settings. Therefore, we decided that the Plan does not have to pay for the therapy services represented by code 
97110 provided on November 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for multiplex PCR respiratory viral panel testing provided on March 15, 2021.

You asked the Plan to pay for viral panel testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation shows that this testing had more than 5 targets which is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. 

We looked at the file and Medicare rules. This testing included 6 or more targets and is therefore non-covered. Based on this information, we decided that Medicare rules for coverage of viral panel testing have not been met. Therefore, we decided that the Plan does not have to pay for multiplex PCR respiratory viral panel testing provided on March 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from October 22, 2021, forward.

You asked the Plan to pre-approve SNF care. You say that you are not ready to discharge from skilled nursing because you cannot take care of yourself. You state that you need more health services so you could get better and stronger. The Plan denied your request. The Plan says the stay is not medically necessary.

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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you no longer qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are ambulating 100 feet. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from October 22, 2021, forward.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for paramedic treatment without transport (A0998) provided on 
February 24, 2021. 
 
You asked the Plan to pay for paramedic treatment without transport. You say that you believe your policy 
covers all claims for 911 emergency services. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport. Effective March 1, 2020, Medicare may pay for ambulance services when there is no 
transport if there is no transport due to local protocols related to the Coronavirus pandemic.  
 
In this case, there is no documentation of relevant Coronavirus protocols. The company that provides the 
paramedic services at issue did not provide transport services on February 24, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for paramedic treatment without transport (A0998) 
provided on February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ankle foot orthotics (L1970) with 
accessories (L2200, L2210, L2275), provided on May 19, 2021. 
 
You asked the Plan to waive the coinsurance for the ankle foot orthotics with accessories. You say that the 
items should be covered. The Plan denied your request. 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. Your 
contract with the Plan says that there is a 20% coinsurance after your in-network $300 deductible which applies 
to prosthetic devices and related supplies. 

The item or service you asked the Plan to waive the coinsurance for falls within the benefit category prosthetic 
devices and related supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a 20% coinsurance after your in-network $300 deductible which applies to prosthetic devices and 
related supplies. This cost sharing is a contractual obligation that had not been met at the time the ankle foot 
orthotics with accessories was received on May 19, 2021. Therefore, we decided that the Plan does not have to 
waive the coinsurance for the ankle foot orthotics (L1970) with accessories (L2200, L2210, L2275), provided 
on May 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) home health (HH) physical therapy (PT) 
services, for the enrollee. 

You asked the Plan to pre-approve the services. You say that the services are medically necessary based on 
acute chronic diastolic (congestive) heart failure. The Plan denied your request. The Plan says the services are 
not necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our physician reviewer 
found the health plan's denial should be upheld. The enrollee does not have documented HH PT needs. The 
enrollee has reached a plateau in function. The enrollee's care needs are custodial. As such, ongoing HH PT is 
not medically necessary or reasonable. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ten (10) home health (HH) physical therapy (PT) services, for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services.

You asked the Plan to waive the copayment for the ambulance services. You say that the claim was processed
with the correct copayment applied per the Evidence of Coverage. The Plan denied your request. The Plan says
you were charged this cost sharing 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 $125
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $125 for these
services. 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 ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a health club membership provided on 
January 17, 2021 under the Wellness Allowance benefit. 
 
You asked the Plan to reimburse you for a health club membership. The Plan denied your request. The Plan 
says it was determined that the total proof of payment received was for the amount of $119 out of the total 
requested $150. As you have already been reimbursed for $50, you are entitled to an additional $69 towards the 
2020 Wellness Allowance Reimbursement. The additional $31 requested remains denied based on lack of proof 
of payment. 

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
The Plan's rules for coverage of gym benefits have not been met because of lack of proof of payment.  
Therefore, we decided that the Plan does not have to reimburse you for a health club membership provided on 
January 17, 2021 under the Wellness Allowance benefit.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an out-of-network
provider on March 12, 2021.

You asked the Plan to pay for the occupational therapy services. You say that the therapy evaluation was
medically necessary to enable the resident to receive therapy that will help attain maximum functionality and
independence. You say that the medical records prove the medical necessity of the services and the claim
should be reprocessed to pay in full. The Plan denied your request. The Plan says prior authorization for out-of-network
services 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 must 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 occupational therapy services provided by an out-of-
network provider on March 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jakafi tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that the enrollee has been stable on this 
medication since 2019. The Plan denied your request. The Plan says the denial of authorization for this drug is 
correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's 
Medicare Part D prescription drug benefits. 
 
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 Jakafi tablets.  
 
Benefits for self-administered drug 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 provided on May 1, 2021.

You asked the Plan to pay for ambulance service, advanced life support, emergency transport, level 1. The Plan denied your request. The Plan says the ambulance services were excluded from coverage citing a "GY" modifier.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 

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 ambulance service, advanced life support, emergency transport, level 1. Our reviewer says that the ambulance services was not medically necessary. Our physician reviewer found that you were transported by ambulance to the hospital with a chief complaint of kidney problems. Your vitals and physical exam were normal. Your doctor told you to go to the hospital due to kidney problems. You were asymptomatic, sitting on your porch. The presenting symptoms do not meet prudent layperson criteria for emergency care. The documentation does not support that other means of transport such as a wheelchair van were contraindicated for you. The documentation does not support that you required expertise, services, or special equipment during transport. The documentation does not support that the ambulance transport on May 1, 2021 was 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 ambulance service, advanced life support, emergency transport, level 1 have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on May 1, 2021.