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

 We decided that the Plan does not have to pay for the office visit provided on February 25, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that the service was medically necessary. 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on February 25, 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 services (63685) provided on July 3, 2019.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.  The Plan must follow Medicare rules. Medicare rules say that code 63685 must be billed with certain secondary diagnosis codes.   We looked at the file and Medicare rules. In this case, code 63685 was billed with secondary diagnosis code G89.4. This diagnosis code is not an appropriate secondary diagnosis code per LCA A57023. 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 pay for the services (63685) provided on July 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chest x-ray provided on July 2, 2021.  You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says this is not a covered screening test.  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, the x-ray, 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 chest x-ray provided on July 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).  You asked the Plan to pre-approve a portable oxygen concentrator. You say that the existing system is too hard for the enrollee to move around with. The Plan denied your request. The Plan says rules for coverage have not been met.  The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.    To qualify for home oxygen, the patient must meet one of the following blood gas levels:  1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;  2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;   3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;  4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.  For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a portable oxygen concentrator. Our reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found that Medicare criteria for a portable oxygen concentrator require documentation of saturation of peripheral oxygen (SpO2) of 91% or above while active using an oxygen conserving device. The provided records do not include that documentation.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds (CPT code K0800).  You asked the Plan to pre-approve the DME. You say that the scooter you have needs to be replaced. The Plan denied your request. The Plan says your request is not medically necessary because it is less than five (5) years old and has been recently repaired.  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. You have a power mobility device which was provided by Numotion on February 16, 2018. It has been repaired in 2020. Therefore, we decided that the Plan does not have to pre-approve the power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds (CPT code K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for continuous positive airway pressure (CPAP) equipment purchased on September 7, 2021.  You asked the Plan to pay for durable medical equipment. You say that you believed you would be charged the price for using an out-of-network provider. The Plan denied your request. The Plan says no payment can be made for a supplier not enrolled in the Medicare program.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for continuous positive airway pressure (CPAP) equipment purchased on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve chiropractor services.  You asked the Plan to pre-approve chiropractor services. You say that these services are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met for these services.  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.   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 chiropractor services Our reviewer says that the requested services are not medically reasonable and necessary based on Medicare coverage rules. Our physician reviewer found the record indicates that the enrollee has a history of back pain. The record indicates an X-ray report that states no subluxation is present. The record does not include a physical examination demonstrating subluxation. 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 chiropractor services have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractor services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (93312) provided on August 25, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.  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, we have confirmed that code 93312 is a column II code to column I code 01926. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (93312) provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ophthalmological services, medical examination provided on September 14, 2021.  You asked the Plan to waive the copayment for ophthalmological services, medical examination. You say that you are titled to one routine eye exam per year with no copayment. You say that you told the doctor that all you wanted was to have a routine eye exam that your insurance pays for. The Plan denied your request. The Plan says the service received is a covered benefit, but the member is disputing the amount assessed by the health Plan for the deductible. Per the Plan benefits, the total $147.83 cost share 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 $500 deductible which applies to the ophthalmological services, medical examination.     The item or service you asked the Plan to waive the copayment for falls within the benefit category for "What is your plan deductible." The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to ophthalmological services, medical examination. This cost sharing is a contractual obligation that had not been met at the time the ophthalmological services, medical examination was received on September 14, 2021. Therefore, we decided that the Plan does not have to waive the copayment for ophthalmological services, medical examination provided on September 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home ventilator.  You asked the Plan to pre-approve the ventilator. You say that this is medically necessary given the enrollee's condition. The Plan denied your request. The Plan says the criteria for the use of a home ventilator have not been met.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 ventilator. Our reviewer says that the documentation does not support the medical necessity of the requested ventilator. Our physician reviewer found this patient was recently hospitalized with an exacerbation of obstructive lung disease, although the records do not include pulmonary function testing or the initial arterial blood gas (ABG) results to support carbon dioxide retention. The patient is severely obese, and obesity-hypoventilation syndrome is likely. The patient improved on bilevel positive airway pressure (BiPAP), with normalization of their blood gas levels.  There is no evidence of BiPAP failure. Medicare does not cover a home ventilator when used for BiPAP.  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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Invega tablets.  

You asked the Plan to pre-approve Invega tablets. You say that the enrollee has been on this drug long-term with excellent efficacy and tolerability. The Plan denied your request. The Plan says Invega tablets are a self-administered drug. The Plan also says that Invega tablets do not fall under Part B coverage.  

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 Invega tablets.   

Benefits for Invega tablets 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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (76705) provided on September 18, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.  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, we have confirmed that code 76705 is a column II code to column I code 76981. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (76705) provided on September 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the shingles vaccine provided to you on September 7, 2021.  You asked the Plan to pay for the shingles vaccine. You say that the vaccine was recommended by your doctor. The Plan denied your request. The Plan says this is not a covered benefit.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules.   The records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided to you on September 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on September 27, 2021.  You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you read the summary of benefits in the enrollment book to say that cleanings were covered, and you did not realize it was deducted from the $500 benefit. You also say that you would like these services to be reprocessed and paid. The Plan denied your request. The Plan says your annual maximum benefit is exhausted.  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 Plan offers a $500 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on April 5, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drugs (J7324) provided on April 29, 2021.  You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says the services were not billed with the correct diagnosis code.  The Plan must follow Medicare rules. Medicare rules say that only certain diagnosis codes support medical necessity of code J7324.   We looked at the file and Medicare rules. The services provided in this case were not billed with an appropriate diagnosis code to support medical necessity as required by LCA A55036. Based on this information, we decided that Medicare rules for coverage of the drugs have not been met. Therefore, we decided that the Plan does not have to pay for the drugs (J7324) provided on April 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (70544) provided on September 4, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.  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, we have confirmed that code 70544 is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (70544) provided on September 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for an office visit/routine physical exam (99204, 99072) rendered on June 23, 2021.  You asked the Plan to waive the deductible for an office visit/routine physical exam. You say that you were told by a representative that this service was free, and you were not told that this provider was out-of-network. You also say the representative implied they were in network and now you are being told that the representative was wrong. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.  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 the "deductible" is the amount you must pay for medical services before the Plan begins to pay its share. The Plan contract says that there is a $500 deductible for all items and services except those specifically excluded by the Plan contract. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. The Plan deductible applies to an office visit/physical exam. The Plan contract also says that there is a 50% coinsurance for an out-of-network PCP's office visit.   You have been asked to pay a $163.35 deductible for an office visit/routine physical exam. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to physician/practitioner services, including doctor's office visits. This means that you have been asked to pay the correct amount based on your contract with the Plan. The deductible is a contractual obligation that had not been met at the time an office visit was received on June 23, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an office visit/routine physical exam (99204, 99072) rendered on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab testing provided on November 3, 2020.  You asked the Plan to pay for the services provided. You say that the diagnosis is acceptable. The Plan denied your request. The Plan says the claim was processed correctly.  The Plan must follow Medicare rules. Medicare rules say that vitamin and metabolic assays are only covered under certain medical indications.   In this case, the CPT Code Manual definition of code 83090 is assay of homocysteine. We find that CPT code 83090 is not supported in the medical record. Specifically, there are insufficient records to show that the testing was ordered for the treatment of an illness. There is no documentation of a comprehensive history or physical exam. 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 lab testing provided on November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent hospital care rendered on August 31, 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 claim is a duplicate.  The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.  We looked at the file and Medicare rules. The file shows that procedure code 99233 (subsequent hospital care) was billed by two physicians in the same practice. Only one code may be paid for these services. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care rendered on August 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the myoelectric upper limb prosthesis with independently articulating digits.  You asked the Plan to pre-approve the myoelectric upper limb prosthesis with independently articulating digits. You say that you would like reconsideration because the requested prosthesis is medically necessary. The Plan denied your request. The Plan says the requested prosthesis exceeds the member's need.  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 myoelectric upper limb prosthesis with independently articulating digits. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found records from the enrollee's treating provider do not document trial and failure of a body-powered prosthesis or other myoelectric prosthesis or provide objective documentation as to why one of these alternative prostheses would be inappropriate for the enrollee. Records from the enrollee's treating provider do not document that the requested myoelectric upper limb prosthesis with independently articulating digits meets but does not exceed the enrollee's needs.  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 myoelectric upper limb prosthesis with independently articulating digits have not been met. Therefore, we decided that the Plan does not have to pre-approve the myoelectric upper limb prosthesis with independently articulating digits.