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

 We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on June 28, 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 medical services provided to the enrollee on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for intra-articular injections of platelet-rich plasma provided to the enrollee on July 23, 2021.  You asked the Plan to pay for the injections. You say that this should be paid for. The Plan denied your request. The Plan says this 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 pay for the injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the intra-articular injections of platelet-rich plasma provided to the enrollee on July 23, 2021 at issue in this case meet Medicare criteria for medically reasonable and necessary. Drugdex/Micromedex has a strong recommendation against use of platelet-rich plasma for osteoarthritis of the hip.  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 injections have not been met. Therefore, we decided that the Plan does not have to pay for intra-articular injections of platelet-rich plasma provided to the enrollee on July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on January 26, 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 services are not covered.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 88374 is 5. The MAI value for this code is 2. You billed 10 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to issue reimbursement for the office visit (99203), the x-ray exam of the knee (73564), the ultrasound, limited, of the joint or other non-vascular extremity structure (76882), and the removal of a knee cyst (27345) rendered by the out-of-network (OON) provider on July 9, 2021.  You asked the Plan to issue reimbursement. 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 issue reimbursement 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 issue reimbursement for these services. Therefore, we decided that the Plan does not have to issue reimbursement for the office visit (99203), the x-ray exam of the knee (73564), the ultrasound, limited, of the joint or other non-vascular extremity structure (76882), and the removal of a knee cyst (27345) rendered by the out-of-network (OON) provider on July 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on April 22, 2021.  You asked the Plan to pay for out-of-network physical therapy. You say that the claim was submitted to Medicare unaware that the benefits were managed by this Plan, so no authorization was obtained. You say that the records support the medical necessity of the treatments and the claim should be approved. The Plan denied your request. The Plan says authorization for out-of-network services has not been 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. Therefore, we decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on April 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor.  You asked the Plan to pre-approve a Freestyle Libre 14-day sensor. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section.  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 Freestyle Libre 14-day sensor. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not indicate that the beneficiary's insulin regimen requires frequent adjustment on the basis of blood glucose testing results.  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 Freestyle Libre 14-day sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on April 8, 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 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 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 medical services provided to the enrollee on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on June 14, 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 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 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 medical services provided to the enrollee on June 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services provided on April 6, 2021, billed with codes 32220 and 32999.  You asked the Plan to pay for the surgical services as billed. You say that it is felt that this was coded correctly. The Plan denied your request. The Plan says not all of the billed codes are supported by the operative report.  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 32220 is Decortication, pulmonary (separate procedure); total. The code 32999 is defined as Unlisted procedure, lungs and pleura.  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the surgical services as billed. Our reviewer says that the codes 32220 and 32999 are not supported in the operative report. Our reviewer found the description for the services described by 32220 states that "the physician removes a constricting membrane or layer of tissue from the surface of the lung (decortication) in order to permit the lung to fully expand. The physician opens the chest cavity widely. Using a scalpel, the surgeon makes a long incision around the side of the chest between two of the ribs. The incision is carried through all the tissue layers into the chest cavity. Rib spreaders are inserted into the wound and the ribs are spread apart exposing the lung. The constricting membrane is stripped off the surface of the lung. Alternately, the chest cavity can be opened by a vertical incision in the front of the chest through the sternum. The skin incision is carried down to the sternum bone and a saw is used to split the sternum. With the sternum split in half, the chest is entered by spreading the sternum apart with a set of rib spreaders." This description is not documented in the operative report for the procedure.  The medical records provided do not include sufficient documentation to validate that an unlisted procedure, lungs and pleura was performed independent of CPT code 32482 which was billed on the same date of service by the same provider and paid by the health plan, therefore, 32999 is inclusive to 32482 and no additional reimbursement is allowed.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services provided on April 6, 2021, billed with codes 32220 and 32999.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the prostate biopsy, the drug administration procedure, the pelvic ultrasound, the ultrasound-guided needle placement, and injection of garamycin you received on July 10, 2021.  You asked the Plan to waive the cost sharing for the biopsy, drug administration, ultrasounds, and drug. You say that you do not think it is fair that you have to pay this cost sharing.  You stated that women are allowed to get mammograms without cost sharing, and this should be treated the same. The Plan denied your request. The Plan says you were charged this cost sharing 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 $35 copayment for services with a specialist. Enrollees also pay a $110 copayment for radiological diagnostic imaging services and 20% coinsurance for Medicare Part B drugs.  You have been asked to pay a $35 copayment for the physician services (i.e., the biopsy and drug administration).  You have been asked to pay a $110 copayment for the ultrasound services and 20% coinsurance for the garamycin injection. 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 cost sharing for the prostate biopsy, the drug administration procedure, the pelvic ultrasound, the ultrasound-guided needle placement, and injection of garamycin you received on July 10, 2021.   Your complaint about prostate services not being treated like mammograms 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for hearing aids provided on January 8, 2021.  You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says hearing aids not purchased from the Plan's hearing network provider are excluded from coverage.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided from a Plan hearing network provider.  We looked at the file and the Plan's rules. The file shows the hearing aids were not provided from a Plan hearing network provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on January 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more toward the oral evaluation, root canal, resin-based composite, nitrous oxide, and sales tax provided on July 15, 2021.   You asked the Plan to pay more toward the oral evaluation, root canal, resin-based composite, nitrous oxide and sales tax. You say that the claim should be paid at the in-network rate since the Plan sent you to this provider. The Plan denied your request. The Plan says the claim processed correctly toward your out-of-network benefits.  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, you also have a maximum benefit of two oral examinations per calendar year. The Plan paid for the oral exam provided on March 22, 2021, and May 26, 2021, which exhausted your benefit. The Plan is only obligated to pay 80% of the cost for a resin filling and root canal from an out-of-network provider. You are responsible for paying the difference between the dentist's fees and the Plan dental fee schedule. Nitrous oxide remains denied as a non-covered benefit. Therefore, we decided that the Plan does not have to pay more toward the oral evaluation, root canal, resin-based composite, nitrous oxide, and sales tax provided on July 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Corus CAD assay rendered on June 18, 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 services are not covered.  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, a cardiovascular risk assessment panel, 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 Corus CAD assay rendered on June 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dialysis and cinacalcet provided from January 31, 2021, through May 31, 2021.  You asked the Plan to pay for the dialysis and cinacalcet. You say that the claim was denied due to an AX modifier issue for Sensipar. You say that you are requesting the claim be reviewed for payment. The Plan denied your request. The Plan says the claim processed 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.  In this case, the CPT Code Manual definition of code 90999 is unlisted dialysis procedure, inpatient or outpatient. The CPT Code Manual definition of code J0604 is cinacalcet, oral, 1 mg (for ESRD on dialysis).  We find that CPT code 90999 and J0604 is not supported in the medical record. Specifically, payment for J0604 is included in the ESRD PPS and separate payment is not made. Billing the AX modifier with CPT code J0604 is no longer appropriate. Based on this information, we decided that Medicare rules for coverage of the dialysis and cinacalcet have not been met. Therefore, we decided that the Plan does not have to pay for the dialysis and cinacalcet provided from January 31, 2021, through May 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on June 21, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary or rest home visit. You say that the assisted living facility is responsible to obtain prior authorization for all of their patients, which should also cover for the medical treatments provided by the doctor. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 domiciliary or rest home visit (99336) provided on June 21, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on July 1, 2020  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 are not covered.  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 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 laboratory services rendered on July 1, 2020
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for Als routine disposable supplies (A0398) provided on  May 5, 2021.  You asked the Plan to pay for Als routine disposable supplies (A0398). The Plan denied your request. The Plan says ambulance supplies are included in the payment rate for the ambulance transport.  The Plan must follow Medicare rules. Medicare rules say that payment for items and services are included in the fee schedule payment.  We looked at the file and Medicare rules. Medicare says that payment for items and services are included in the fee schedule payment. Therefore, we decided that the Plan does not have to pay for Als routine disposable supplies (A0398) provided on May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Duet rollator/transport chair (E0143, E0156).  You asked the Plan to pre-approve a rollator/transport chair. You say that the requested items are a necessity for your care. The Plan denied your request. The Plan says the requested items are not a covered benefit.  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 a rollator/transport chair. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested combination rollator and transport chair exceeds your medical needs. There is no evidence that you are unable to effectively perform MRADLs in the home with a standard walker.   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 rollator/transport chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a Duet rollator/transport chair (E0143, E0156).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for Meningococcal vaccine (90620) provided March 15, 2021.  You asked the Plan to pay for Meningococcal vaccine. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says certain preventative immunizations and their administration is not a Medicare covered benefit.    In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Meningococcal vaccine. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to Meningococcal vaccine. Therefore, we decided that the Plan does not have to pay for Meningococcal vaccine (90620) provided March 15, 2021.