Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive copayments charged for ambulance transport provided from April 28, 2021, to May 3, 2021.

You asked the Plan to waive these copayments. You say that the ambulance company told you to call the Plan and ask for the Covid-19 waiver because your husband had Covid-19 and could not take you to the hospital. The Plan denied your request. The Plan says these copayments were charged based on your Plan contract. The Plan is covering your decision to call the ambulance and granted the Covid-19 waiver for ambulance transport. This means even though you may have been able to go in a vehicle other than an ambulance, coverage for the transport has been approved. However, this does not waive the copayments.

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 $250 for each one-way ambulance transport.

While it is true Medicare rules for ambulance coverage were relaxed to allow transport that may or may not have been medically necessary, Medicare is not requiring the Plan to waive the copayments for these services. 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 copayments charged for ambulance transport provided from April 28, 2021, to May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a pharmacogenetic panel (81225, 81230, 81240, 81241, 81291).

You asked the Plan to pay for a pharmacogenetic panel. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. If a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so 1 code must be submitted for the panel. 

We find that CPT codes 81225, 81230, 81240, 81241, and 81291 are not supported in the medical record. Specifically, these codes were used to report a panel, which should be billed with a single code.

Based on this information, we decided that Medicare rules for coverage of a pharmacogenetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a pharmacogenetic panel (81225, 81230, 81240, 81241, 81291).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services provided on December 9, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services 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 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 wound care services provided on December 9, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (84480) provided on May 29, 2020.
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 84480 has a bundled relationship with code 84481 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 (84480) provided on May 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 14, 2020 by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating 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 requested provider in this case is not a network provider with the Plan. The referring provider 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 laboratory services provided on August 14, 2020 by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) and the laboratory service (81002) rendered by the out-of-network (OON) provider on April 12, 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 (99204) and the laboratory service (81002) rendered by the out-of-network (OON) provider on April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided on June 3, 2021. 
 
You asked the Plan to waive the copayment for lab services. You say that you do not believe you have had 
copayments for lab work in the past. The Plan denied your request. The Plan says the copayment applied was 
correct. 
 
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 $10 
copayment for each Medicare-covered lab test.  
 
You have been asked to pay a $10 copayment for lab services. Lab services fall within the outpatient diagnostic 
tests and therapeutic services and supplies 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 lab services provided on June 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided on January 19,
2021.
You asked the Plan to pay for the additional supplies and materials. You say that the medical records fully
support and justify billing code 99072. You say that the daily notes show the kind of precautions taken and the
code should be reprocessed for payment. The Plan denied your request. The Plan says bundled services are not
eligible for separate reimbursement.
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 99072 is additional supplies, materials, and clinical staff
time over and above those usually included in an office visit or other non-facility service(s), when performed
during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.
We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status
indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on
this information, we decided that Medicare rules for coverage of the additional supplies and materials have not
been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials
provided on January 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Go Go Elite Scooter 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a wheelchair from 2017 that meets mobility needs within the home. 
 
The Plan follows Medicare rules. The Plan must follow Medicare rules. The rules state that for equipment to be 
covered, it must be appropriate and needed for use inside the home. 
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found the records indicate 
that this requested scooter is for use outside of home. The records indicate that the enrollee walks "prolonged 
distances to his shed." It is not clear from the provided records that the enrollee's mobility deficit cannot be 
helped by the use of a walker, cane, or manual wheelchair. There is no documentation that there any specific 
need for this scooter when the enrollee already has a wheelchair. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Go Go Elite Scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have extreme pain, and she needs to walk. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Polysomnography. 
 
You asked the Plan to pre-approve a Polysomnography. The Plan denied your request. The Plan says the 
member has already had a diagnostic polysomnogram in January 2021. Assessment of that study diagnosed 
Moderate OSA. An auto CPAP was recommended. Compliance was the issue with the member. A repeat sleep 
study is not needed. 
 
The Plan follows Medicare rules. Medicare rules say that a follow-up polysomnography or a cardio-respiratory 
sleep study is indicated for the following conditions: 

To evaluate the response to treatment (CPAP, oral appliances or surgical intervention); after substantial weight 
loss has occurred in patients on CPAP for treatment of sleep-related breathing disorders to ascertain whether 
CPAP is still needed at the previously titrated pressure; after substantial weight gain has occurred in patients 
previously treated with CPAP successfully, who are symptomatic again despite continued use of CPAP, to 
ascertain whether pressure adjustments are needed; or when clinical response is insufficient or when symptoms 
return despite a good initial response to treatment with CPAP. 
 
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 Polysomnography. Our reviewer says 
that a repeat Polysomnography does not meet the Medicare coverage criteria. Our physician reviewer found 
that the enrollee has already had a diagnostic polysomnogram in January 2021. Assessment of that study 
diagnosed Moderate OSA. An auto CPAP was recommended. Compliance was the issue with the enrollee. A 
repeat sleep study is not needed. The review has determined that the enrollee does not meet the Medicare 
coverage criteria for a repeat Polysomnography. 
 
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 Polysomnography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Polysomnography.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental implant and bone grafts (21248, 21249, 21215, 41870 and 41899).
You asked the Plan to pre-approve the dental implant and bone grafts. You say that the services are medically necessary.. The Plan denied your request. The Plan says these are not covered services.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the dental implant and bone grafts (21248, 21249, 21215, 41870 and 41899).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the benefit provides coverage for the requested viscosupplement when medically necessary.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires that these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered or that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, Durolane is not approved, as step criteria have not been met. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen supplies you received on July 9, 2021.
You asked the Plan to waive the coinsurance for the oxygen supplies. You say that you were told you would not have to pay anything for oxygen supplies. You said that you didn't have to pay anything for these supplies with your old insurance. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment and related supplies. You have been asked to pay 20% coinsurance for the oxygen supplies. The oxygen supplies fall within the durable medical equipment and related supplies 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 oxygen supplies you received on July 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has been no trial and failure of the preferred step therapy drugs. 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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not 
trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, 
requires that these be trialed first. The documentation does not outline contraindications or reasons these 
medications were not considered or that the plan's required drugs would likely be less effective and/or likely 
have adverse effects for the enrollee. Without the support of the documentation, Synvisc is not approved as step 
criteria have not been met. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc-One for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact 
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam 
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42 
CFR Section 411.15(c). 
 
The rules say that a contract plan provider is an agent of the plan. Services and referrals obtained from a plan 
provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan 
provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, 
the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.  
 
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or 
item is never covered, the plan does not have to hold the enrollee harmless.  
 
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone 
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-16, Medicare Managed Care Manual, Chapter 4, Section 160. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that the Plan covers a Routine Eye Exam (1 per calendar year). The eye exam will include 
refraction and dilation. You can find this information on page 87 of the Plan's 2021 Evidence of Coverage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental bridge work services (D6057, D6068, D6245, D6057, D6068).

You asked the Plan to pre-approve the dental bridge work services. You say that this request is medically necessary. The Plan denied your request. The Plan says these services are specifically excluded from coverage under your benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under the specific group 1 dental benefit package. Therefore, we decided that the Plan does not have to pre-approve the dental bridge work services (D6057, D6068, D6245, D6057, D6068).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre sensors (K0553) for the enrollee.
You asked the Plan to pre-approve Freestyle Libre sensors. You say that the enrollee needs better glucose control. The Plan denied your request. The Plan says that you do not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre sensors (K0553) for the enrollee.