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

 We decided that the Plan does not have to pre-approve platelet rich plasma injections.  You asked the Plan to pre-approve platelet rich plasma injections. You say that this is medically necessary for your condition. The Plan denied your request. The Plan says this procedure is considered experimental/investigational.  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 platelet rich plasma injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that there is not enough research to show that platelet-rich plasma (PRP) or autologous platelet-derived growth factor (PDGF) treatment improves health outcomes for any indication. In addition, there are no clinical guidelines that recommend the use of PRP or PDGF. The requested items/services at issue in this case are 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 platelet rich plasma injections have not been met. Therefore, we decided that the Plan does not have to pre-approve platelet rich plasma injections.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99214, 90662, G0008, 83036) provided on September 22, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is a non-participating provider, and the referring provider is a non-participating provider with the Plan. The Plan also says they did not authorize any services for this provider or service.  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 an office visit (99214, 90662, G0008, 83036) provided on September 22, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cytopathology services (88172) provided on July 20, 2021.
You asked the Plan to pay for cytopathology services. You say that the enrollee had multiple exams. The Plan
denied your request. The Plan says this is not separately payable.
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 88172
is a column II code to column I code 88333. 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 cytopathology services (88172) provided on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve two simple extractions (D7140 x2) and a complete mandibular denture (D5120).  You asked the Plan to pre-approve the simple extractions and complete mandibular denture. You say that tooth #'s 21 and 22 are both rotten and it hurts when you try to eat. You also say that your gum is often swollen, and you would like these services to be approved for coverage. The Plan denied your request. The Plan says these services are not covered 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 this benefit. Therefore, we decided that the Plan does not have to pre-approve two simple extractions (D7140 x2) and a complete mandibular denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office visit provided to the enrollee on September 7, 2021.  You asked the Plan to pre-approve services. You say that this should be paid for. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal.  We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit provided to the enrollee on September 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the insertion of ventricular assist device (33979) provided on March 11, 2021.  You asked the Plan to pay for the insertion of ventricular assist device (33979). You say that the provider thought it necessary to address the heart failure issue as well which required an assistant surgeon. You say that the services ordered by the physician were reasonable due to the patient's condition and the claim should be reprocessed for payment. The Plan denied your request. The Plan says the procedure was performed in a location not approved for Ventricular Assist Devices.  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 33979 is insertion of ventricular assist device, implantable intracorporeal, single ventricle.  We find that CPT code 33979 is not supported in the medical record. Specifically, the billing facility is not an approved facility for Ventricular Assist Devices. Based on this information, we decided that Medicare rules for coverage of the insertion of ventricular assist device (33979) have not been met. Therefore, we decided that the Plan does not have to pay for the insertion of ventricular assist device (33979) provided on March 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0427) provided on May 12, 2021.  You asked the Plan to waive the copayment for the ambulance transportation. You say that you are being billed for these services, but they should be covered by your health insurance or auto insurance. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. Ambulance services require a $250 copayment.  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 $250 copayment for ambulance services.    You have been asked to pay a $250 copayment for the ambulance transportation. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0427) provided on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for initial hospital care (99222) provided on August 4, 2021.  You asked the Plan to pay for initial hospital care. You say that this can be paid in an inpatient setting. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that physicians/practitioners who furnish services to a hospital outpatient, including in a hospital outpatient department (including in a provider-based department of that hospital) or under arrangement to a hospital shall, at a minimum, report the off campus-outpatient hospital place of service (POS) code 19 or on campus-outpatient hospital POS code 22 irrespective of the setting where the patient actually receives the face-to-face encounter.  We looked at the file and Medicare rules. The service at issue was billed with the inpatient hospital POS code 21, but the record indicates that the enrollee was admitted as an outpatient for observation. Based on this information, we decided that Medicare rules for coverage of initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for initial hospital care (99222) provided on August 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).  You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that the member has suffered from this condition for several years and has failed more than 6 months of conservative approaches to treatment. You say that this treatment is considered safe and effected and the necessary coverage should be provided. The Plan denied your request. The Plan says this service is considered experimental and investigational.  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 insertion of stabilization device (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the interspinous process distraction devices remain experimental in spinal surgery.    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 insertion of stabilization device (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve balloon dilation services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve balloon dilation services. You say that you have verified you are an in-network provider. The Plan denied your request. The Plan says there are in-network providers available to treat the enrollee's condition.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has specifically confirmed that there is no documentation in place that says otherwise.  The Plan has network providers available who can provide the items/services at issue in this appeal.   We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve balloon dilation services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the MyoPro 2 Motion G orthotic device (L8702).  You asked the Plan to pre-approve the orthotic device. You say that while the enrollee has not suffered a stroke, it is important to recognize that the technology in question is appropriate for neurological arm weakness, regardless of etiology. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro 2 Motion G orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a non-spinal electrical osteogenesis stimulator (E0747).  You asked the Plan to pre-approve a non-spinal electrical osteogenesis stimulator. You say that you need this because you cannot bear weight. The Plan denied your request. The Plan says the requirements for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that a non-spinal electrical osteogenesis stimulator (E0747) is covered only in the event of nonunion of a long bone fracture, failed fusion of a joint other than in the spine where a minimum of nine months has elapsed since the last surgery, or congenital pseudarthrosis.  We looked at the file and Medicare rules. The records show that you do not have a long bone fracture or congenital pseudarthrosis and that it has been fewer than 9 months since your most recent surgery. Based on this information, we decided that Medicare rules for coverage of a non-spinal electrical osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-spinal electrical osteogenesis stimulator (E0747).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional eyewear benefits in 2021.  You asked the Plan to pre-approve additional eyewear. You say that you did receive new lenses on March 19, 2021, but you did not know these would be applied to your benefit as you did not also have an eye exam at that time. You say some of these lenses did not fit right and you lost them. You feel that the Plan should allow you to use this benefit again within the timeframe. The Plan denied your request. The Plan says you previously used your eyewear benefit on March 19, 2021. This benefit is limited to one use per year. You exhausted the benefit for contact lenses in 2021. Your complaint regarding the contact lenses that you did not receive is being addressed separately as a grievance. Please note that you may use your 2022 benefit at any time during 2022.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to $125 once per year.  We looked at the file and the Plan's rules. Documentation shows that you previously purchased contact lenses in March of 2021. The total cost of the eyeglasses was $146, and the Plan paid the full $125 allowance at that time which left you responsible for $21. Based on this information, we decided that the Plan's denial of additional eyewear benefits in 2021 was correct. Therefore, we decided that the Plan did not have to pre-approve additional eyewear benefits during the 2021 plan year. Please note that this decision was made using your 2021 benefits, and you may be eligible for new benefits in 2022.  Your complaint about the ill-fitting or missing lenses you received is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral to an out-of-network chiropractor.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network chiropractor.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cystourethroscopy (52000) provided by a surgical assistant on August 2, 2021.  You asked the Plan to pay for the cystourethroscopy (52000). You say that the doctor's office and surgical group failed to submit documentation accurately for an approved authorization. The Plan denied your request. The Plan says CPT code 57425 has been overturned and CPT code 52000 remains denied as an assistant surgeon may not be paid for this procedure.  The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 52000. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the cystourethroscopy (52000) have not been met. Therefore, we decided that the Plan does not have to pay for the cystourethroscopy (52000) provided by a surgical assistant on August 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided September 5, 2021.  You asked the Plan to waive the copayment for the non-emergency ambulance services and ground mileage. You say that you did not ask to be transported, and don't feel you should be responsible for the cost. The Plan denied your request. The Plan says the copayment was applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each oneway Medicarecovered ground ambulance trip.  You have been asked to pay a $250 copayment for the non-emergency ambulance services and ground mileage. The non-emergency ambulance services and ground mileage falls within the Ambulance services 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 ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided September 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0675).  You asked the Plan to pre-approve a pneumatic compression device. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says a PCD coded as E0675 is used only for peripheral artery disease and not covered.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0675).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on October 20, 2021.  You asked the Plan to pay for the dental service. You say that you have been having intermittent pain in your lower right jaw area. You say that your doctor recommended a full mouth series of x-rays. You also say that you were not aware that this service would not be covered. The Plan denied your request. The Plan says complete series x-ray is not listed as a covered service.  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 complete series x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on October 20, 2021.