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

We decided that the Plan does not have to waive the copayment for the ophthalmology exam provided on June 3, 2021.
You asked the Plan to waive the copayment for the ophthalmology exam. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an ophthalmology exam on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 exams to diagnose and treat diseases and conditions of the eye. We looked at the file, the Plan's contract and Medicare rules. The file shows that you had an ophthalmology
exam to diagnose degenerative myopia and other migraines. You have been asked to pay a $50 copayment for the ophthalmology exam. The ophthalmology exam falls within the Vision care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ophthalmology exam provided on June 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sixty (60) additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that the services are
necessary. The Plan denied your request. The Plan says you exhausted your benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case.
We looked at your request, the records in the case file, and the rules. This request exceeds your benefit. The
health plan contract says up to 60 one-way trips, combined in and out-of-network, are covered per calendar
year (limited to ground transportation only). The 61st trip and beyond is not a covered benefit. Therefore, we
decided that the Plan does not have to pre-approve sixty (60) additional routine transportation trips.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on April 19, 2021.

You asked the Plan to pay for the services provided. You say that medically necessary services were provided in good faith. The Plan denied your request. The Plan says coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that contingent upon the patient's consent, the CP will attempt to consult with the attending or primary care physician in accordance with accepted professional ethical norms. 

We looked at the file and Medicare rules. The records provided do not include attempts to consult with the enrollee's attending or primary care physician. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient mental health services provided on April 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomics panel testing provided on December 29, 2020.
You asked the Plan to pay for the testing services. You say that the denied codes are payable. The Plan denied your request. The Plan says one CPT code must be submitted for the panel.
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 looked at the file and the rules. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomics panel testing provided on December 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 1, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the services provided. You say that you always go to this lab. The Plan denied your request. The Plan says the services were not authorized.

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 lab 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 lab services provided on June 1, 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 electronic connection between wheelchair controller and
two or more power seating system motors, including all related electronics, indicator feature, mechanical
function selection switch, and fixed mounting hardware (CPT code E2311), expandable controller, including
all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), and harness
for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each (CPT
code E2313) for the enrollee.

You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your
request. The Plan says the DME is not necessary.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. The upgraded electronics (expandable
controller, harness and electronic connector to 2 power options) are not medically necessary. They are
necessary when there is a medical need to control power options though the joystick. The notes do not show a
medical need to control the power options through the joystick. Therefore, we decided that the Plan does not
have to pre-approve electronic connection between wheelchair controller and two or more power seating
system motors, including all related electronics, indicator feature, mechanical function selection switch, and
fixed mounting hardware (CPT code E2311), expandable controller, including all related electronics and
mounting hardware, upgrade provided at initial issue (CPT code E2377), and harness for upgrade to
expandable controller, including all fasteners, connectors and mounting hardware, each (CPT code E2313) for
the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Esophagogastroduodenoscopy (43235) provided on December 10, 2020.
You asked the Plan to pay for the Esophagogastroduodenoscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support CPT code 43235.
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 43235 is Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure).
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 Esophagogastroduodenoscopy. Our reviewer says that CPT code 43235 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report does not support CPT 43235 was a distinct separate procedure, and would be inclusive to CPT 43633 reported same day. Modifier 59 should be appended to distinguish different session or patient encounter, or different procedure, surgery or anatomical site, or separate injury. 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 Esophagogastroduodenoscopy have not been met. Therefore, we decided that the Plan does not have to pay for the Esophagogastroduodenoscopy (43235) provided on December 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 28,
2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says there is no network deficiency for the services, and alternate network providers were found.
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 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 laboratory services provided to the enrollee on
December 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral exam (D0150) on June 8, 2021.
You asked the Plan to pay for a comprehensive oral exam. You say that this should be covered fully. The Plan denied your request. The Plan says one comprehensive oral evaluation is allowed every 36 months. The Plan says that you have already exhausted this benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one comprehensive oral exam every 36 months. We looked at the file and Medicare rules. Evidence was provided that a comprehensive oral evaluation was provided on December 3, 2020. This means that the benefit limit for coverage of this service in 2021 has been exhausted. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral exam have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral exam (D0150) provided on June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and related accessory (E0673) provided on March 29, 2021.
You asked the Plan to pay for a pneumatic compression device and related accessory. You say that you would like these claims reprocessed after a confirmation of the place of service codes. The Plan denied your request. The Plan says these items are not covered under Medicare.
The Plan must follow Medicare rules. Medicare rules say that a PCD is only used for treatment of peripheral artery disease and is statutorily non-covered by Medicare. In addition, a PCD-related accessory will be denied if the base PCD is not covered. We looked at the file and Medicare rules. The PCD coded as E0675 is statutorily non-covered by Medicare. IN addition, since the related base is not covered the accessory coded as E0673 is also not covered. Based on this information, we decided that Medicare rules for coverage of a pneumatic compression device and related accessory have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and related accessory (E0673) provided on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic service (98941) provided on June 24, 2021.
You asked the Plan to pay for the chiropractic service. You say that the services were medically necessary, and you were not made aware that this provider was out-of-network. The Plan denied your request. The Plan says there were network providers available.
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 services 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 these services. Therefore, we decided that the Plan does not have to pay for chiropractic service (98941) provided on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro orthotic device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health
problem.
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 the device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that at this time, the requested robotic orthosis is not proven to be more beneficial for treatment of the
enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy such as
conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy,
conventional muscle strengthening, and Botox for spasticity if needed. The MyoPro is not known to be
effective, based on scientific evidence, professional standards, and expert opinion, in improving health
outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is
insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this
patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the
literature that this device will increase participation in bimanual activities. The requested device is not
reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a
malformed body member.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the MyoPro orthotic device for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services provided on February 22, 2021.
You asked the Plan to pay for the services provided. You say that the services have produced significantly better outcomes. The Plan denied your request. The Plan says experimental and investigational services are 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 services provided. Our physician reviewer found that the enrollee has chronic bilateral foot pain and paresthesia. She had NeoGen-series therapy, vasopneumatic therapy and subcutaneous injection of a nutri-pharmaceutical blend. This is not evidence-based therapy and is considered experimental/ investigational. 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 the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the pain management services provided on February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), bitewings - four radiographic images (D0274), prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120), resin-based composite - two surfaces, posterior (D2392), and resin-based composite - one surface, anterior (D2330) provided March 10, 2021, to March 31, 2021.
You asked the Plan to provide additional payment for the intraoral x-rays, bitewing x-rays, dental cleaning, periodic oral exam and resin-based composite fillings. You say that you were told the services would be covered. The Plan denied your request. The Plan says the services have been re-processed correctly. You are
responsible for the difference between the allowed amount and the total cost charged by an out-of-network provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one intraoral x-ray per calendar year. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions. You may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider. We looked at the file and Medicare rules. The Plan has covered one intraoral x-ray on March 10, 2021; therefore, the second intraoral x-ray is not covered. The Plan has provided coverage for the remaining services. The OON provider may bill for any amount greater than the payment made by the Plan to the provider. Therefore, we decided that the Plan does not have to provide additional payment for the intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), bitewings - four radiographic images (D0274), prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120), resin-based composite - two surfaces, posterior (D2392), and resin-based composite - one surface, anterior (D2330) provided March 10, 2021, to March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on May 12, 2021, by an
OON provider.
You asked the Plan to pay for the physician 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 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 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 physician services provided on May 12, 2021,
by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on April 17, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the self-administered drugs provided to you are not covered under your Medicare Part B 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 pay for the self-administered drugs provided on April 17, 2021.
Benefits for the self-administered drugs 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion pump provided on December 31, 2020.
You asked the Plan to pay for the infusion pump. The Plan denied your request. The Plan says the billed service cannot be verified.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the infusion pump provided on December 31, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health visits for the enrollee.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not support the need for a skilled nurse to make more visits.
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 visits. Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that skilled nursing or skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. There is no report in the available records of any acute change in condition to support the request for additional skilled nursing services beyond what has already been 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home health visits for the enrollee.