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

We decided that the Plan does not have to pay for a polarized lens option and a miscellaneous frame charge provided on September 8, 2021.
You asked the Plan to pay for a polarized lens option and a miscellaneous frame charge. You say that your eyes are sensitive to light, and you need the polarized coating. The Plan denied your request. The Plan says polarized lenses and the $25 miscellaneous frame charge are not shown as covered services, and they are specifically referenced in the exclusionary language of the EOC.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that polarized lenses and the $25 miscellaneous frame charge are not shown as covered services, and they are specifically referenced in the exclusionary language of the EOC. Therefore, we decided that the Plan does not have to pay for a polarized lens option and a miscellaneous frame charge provided on September 8, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva.
You asked the Plan to pre-approve Xgeva. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 Xgeva. Our reviewer says that the medication is not medically necessary. Our physician reviewer found based on the medical records provided there is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to pre-approve Xgeva.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99215) and the state tax (99999) rendered by the out-of-network (OON) provider on November 3, 2020.
You asked the Plan to pay for this item/service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service 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 this service. Therefore, we decided that the Plan does not have to pay for the office visit (99215) and the state tax (99999) rendered by the out-of-network (OON) provider on November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on August 19, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for out of network services provided to the enrollee on August 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power wheelchair and repair services provided on July 23, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the power wheelchair and repair services. You say that the items should be covered. The Plan denied your request. The Plan says these services could have been provided in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for the power wheelchair and repair services provided on July 23, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the wig purchased on May 18, 2021.

You asked the Plan to pay for the wig. You say that you would like reimbursed for this. The Plan denied your request. The Plan says that this is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. 

In this case, although the wig may be appropriate for you, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Therefore, we decided that the Plan does not have to pay for the wig purchased on May 18, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the genetic testing provided on May 12, 2021.
You asked the Plan to pay for the services provided. You say that this testing should not have been performed. The Plan denied your request. The Plan says that the services were not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. We looked at the file and the rules. The Plan has not provided a claim, order form, or even test results that show the services were not medically necessary. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the genetic testing provided on May 12, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on June 7, 2021.

You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a physician assistant, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Senexas treatment provided on June 28, 2021.
You asked the Plan to pay for the senexas treatment. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that edicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. The rules also say that beginning in July 2015, claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the senexas treatment have not been met. Review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy. 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. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid Therefore, we decided that the Plan does not have to pay for the Senexas treatment provided on June 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone-acetaminophen.
You asked the Plan to pre-approve Oxycodone-acetaminophen. You say that the medication is necessary. The Plan denied your request. The Plan says you have a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Oxycodone-acetaminophen.
Benefits for Oxycodone-acetaminophen 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for retreatment of previous root canal therapy (D3346) provided on July 23, 2021.
You asked the Plan to pay for retreatment of previous root canal therapy. You say that this service was necessary, and you were in significant pain. You are disappointed with the amount the Plan paid for these services and this bill is an extreme financial hardship. The Plan denied your request. The Plan says the root canal is covered, but the Plan only pays up to a certain amount for covered dental services. When you see an out-of-network provider, you are responsible for the difference between what the provider bills and what the Plan pays.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. 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 $0 copayment for root canals (endodontic services). However, if you choose to see an out-of-network dentist, you might be billed for charges above what the Plan pays, even for services listed as a $0 copayment. The Plan only pays up to a certain amount. If you choose to see an out-of-network dentist, you might be billed for any amount greater than what the Plan pays.
The provider billed $1,900 for the root canal retreatment provided on July 23, 2021. The Plan's maximum allowed charge for this service is $510. This is the amount that an in-network provider has agreed to accept as full payment; however, out-of-network providers do not have this agreement and are allowed to bill enrollees the remaining charges. The Plan has paid the full maximum allowed amount, and you are responsible for $1,390 ($1,900 - $510 = $1,390). 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 pay any additional amount for the retreatment of previous root canal therapy (D3346) provided on July 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance provided on August 24, 2021.
You asked the Plan to pay for periodontal maintenance. You say that you have filed reimbursement claims for this provider for two years and this is the only claim that denied. You say that you get $1,000 per year in dental coverage, and you should be reimbursed. The Plan denied your request. The Plan says if you use a provider that has opted out of Medicare you will not receive reimbursement.
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, dental services provided by a dentist that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periodontal maintenance provided on August 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound of the heart (93306) provided on June 1, 2020.

You asked the Plan to pay for an ultrasound of the heart. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the request is a duplicate of a previously processed claim.

The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an ultrasound of the heart have not been met. Specifically, the Plan has documented that the claim at issue is a duplicate of a prior claim that has been processed and paid. Therefore, we decided that the Plan does not have to pay for an ultrasound of the heart (93306) provided on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for injections (J7323) provided August 3, 2021.  You asked the Plan to waive the coinsurance for the injections. You say that the copayment should be waived as you were told one copayment covered all the injections. The Plan denied your request. The Plan says the correct copayment was applied.  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% coinsurance for Part B Drugs.   You have been asked to pay a 20% ($55.41) coinsurance for the injections. The injections fall within the Part B Drugs 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 coinsurance for injections (J7323) provided August 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on April 10, 2020.  You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says procedures that represent overlapping services are mutually exclusive. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  The file shows that CPT code 70450 was billed with code 70496. We find that CPT code 70450 may be eligible for payment when billed with this code pair. The claim information does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on April 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Gogo motorized cart and sales tax, purchased on November 20, 2021.  

You asked the Plan to pay for the Gogo motorized cart and sales tax. You say that the item is medically necessary. The Plan denied your request. The Plan says this item does not primarily service a medical purpose and sales tax is not covered benefit.  

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the Gogo motorized cart and sales tax, purchased on November 20, 2021.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pay for skilled nursing facility (SNF) services provided to the enrollee from January 29, 2020 to January 31, 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 that the additional documentation received supports DAYE1 x3 days.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan did not make any specific argument as to which functional abilities are felt to be incorrectly scored. The plan has not provided enough evidence to claim that the assessment coding was not done correctly. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) services provided to the enrollee from January 29, 2020 to January 31, 2020.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological services provided on August 9, 2021.  

You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says 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 Plan says that the Plan has 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 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 ophthalmological services provided on August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) testing panel provided on May 25, 2021, billed with code 81455.  

You asked the Plan to pay for the F1Heme panel. You say that this is a medically necessary test that will help with patient management. The Plan denied your request. The Plan says this panel exceeds the enrollee's medical need.  

The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to support the medical necessity of Genomic Sequential Analyses panels for patients with myelodysplastic disease for a limited number of individual biomarkers. Panels which test the covered biomarkers and are described by code 81450 may be covered by Medicare.   

We looked at the file and Medicare rules. Review of the information in the file shows that this panel includes analysis of over 50 genes. The billed code 81455 is defined as targeted genomic sequencing with analysis for 51 or more genes. Although some of these genes may be considered medically necessary based on the rules, the entire panel exceeds what is covered under these provisions. Based on this information, we decided that Medicare rules for coverage of the F1Heme panel have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) testing panel provided on May 25, 2021, billed with code 81455.