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

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B prescription drug provided on April 1, 2021.
You asked the Plan to waive the coinsurance for a Medicare Part B prescription drug. You say that the injection is to prevent cancer and you were never charged in the past. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 Medicare Part B prescription drugs. You received a Medicare Part B prescription drug on April 1, 2021. The total allowed amount is $393 an 20% of that is $78.60. You have been asked to pay the total coinsurance amount of $78.60 for a Medicare Part B prescription drug. A Medicare Part B prescription drug falls within the Medicare Part B prescription 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 a Medicare Part B prescription drug provided on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that this is a post-op appointment. The Plan denied your request. The Plan says these services can be 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 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 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 foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the enrollee has permanent lifelong foot and
ankle issues. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on June 29, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for skilled nursing services. You say that these services were provided in good faith that reimbursement would be made. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that the prior authorization was not obtained by the member's primary care physician.

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 skilled nursing services provided on June 29, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anterior resin-based composites (D2332) and posterior resin-based composite (D2392) provided on February 1, 2021.
You asked the Plan to pay for the resin-based composites. You say that you believe fillings should be covered in full. The Plan denied your request. The Plan says your annual maximum benefit has been exhausted. The Plan also says that your dental rider was disenrolled on January 31, 2021.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $500 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are
responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit while processing this claim for the February 1, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the anterior resin-based composites (D2332) and posterior resin-based composite (D2392) provided on February 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical stockings (A4500) provided on March 10, 2021.

You asked the Plan to pay for surgical stockings. You say that this is supported in the records. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that surgical stockings (A4490, A4495, A4500, A4510) are non-covered under the surgical dressing benefit because they do not meet the statutory definition of a dressing. 

We looked at the file and Medicare rules. The item at issue is excluded from coverage. Based on this information, we decided that Medicare rules for coverage of surgical stockings have not been met. Therefore, we decided that the Plan does not have to pay for surgical stockings (A4500) provided on March 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for external electrocardiographic recording provided on April 11, 2020 by an out-of-network provider.

You asked the Plan to pay for external electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; recording (includes connection and initial recording) (0296T) and external electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; scanning analysis with report (0297T). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there are no medical record leading up to the actual service and prior authorization was not requested.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. There are no medical notes from before the service to determine medical necessity. 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 external electrocardiographic recording provided on April 11, 2020 by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided in an outpatient setting from January 8, 2021, to January 10, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you did not self-administer these drugs. You say that they were given to you in the hospital. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
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 pay for the self-administered drugs (A9270) provided in an outpatient setting from January 8, 2021, to January 10, 2021.
Benefits for the self-administered drugs 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc injections (J7320).

You asked the Plan to pre-approve Genvisc. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

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 Genvisc. Our reviewer says that the requested Genvisc injections are not medically necessary. Our physician reviewer found there is no clinical rationale for the requested Genvisc injections given the reported results for Orthovisc therapy. The enrollee reported no relief from the previous Orthovisc injections. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Genvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc injections (J7320).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs). You say that have been diagnosed with hypertension and you take medications for this condition. The Plan denied your request. The Plan says the certification dated August 10, 2021 documented that the enrollee has none of the qualifying diagnoses, does not require intense care coordination, and has no high risk for hospitalizations or high risk for adverse health outcomes. The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. We looked at the file and the Plan's rules. The file shows that your medical conditions are not eligible medical conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas neoGen-Series Therapy and the subcutaneous injection provided on July 30, 2020.

You asked the Plan to pay for vasopneumatic device therapy procedure and subcutaneous injection. You say that the enrollee needed the procedures because of intense cramping in legs and feet overnight. The Plan denied your request. The Plan says there is no documentation noting the presence of edema.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. The device is to reduce edema or lymphedema, treatment of peripheral neuropathy with this device is not considered medically reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of vasopneumatic device therapy have not been met. Therefore, we decided that the Plan does not have to pay for Sanexas neoGen-Series Therapy and the subcutaneous injection provided on July 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional $107.99 toward the 2020 Wellness Allowance.
You asked the Plan to reimburse you an additional $107.99 toward the 2020 Wellness Allowance. You say that you are asking for the additional $107.99 to be refunded to you based on the expenses you submitted. The Plan denied your request. The Plan says no additional proof of payment was submitted for the remaining balance of $107.99 for your 2020 Wellness Allowance. The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because the file shows that the Plan has not received additional proof of payment. Therefore, we decided that the Plan does not have to reimburse you an additional $107.99 toward the 2020 Wellness Allowance for exercise classes provided on October 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 24, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there are not authenticated medical records from the ordering provider.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. The records provided also do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 24, 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. The Plan denied your request. The Plan says this is not covered under the enrollee's plan.
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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided on November 16, 2020, to December 16, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for acupuncture services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says these services were provided out-of-network. The Plan says that the member's primary care physician did not refer these services.
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 acupuncture services provided on November 16, 2020, to December 16, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on January 29, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 provided on January 29, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on May 1, 2020, to May 8, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for outpatient services. You say that you would like this reprocessed and paid due to medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is also out-of-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 outpatient services provided on May 1, 2020, to May 8, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the gingival irrigation - per quadrant (D4921) provided May 7, 2021.
You asked the Plan to pre-approve the gingival irrigation. You say that you would like the service covered. The Plan denied your request. The Plan says this service is not covered under your 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, 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 the gingival irrigation - per quadrant (D4921) provided May 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator provided from December 18, 2020, to February 18, 2021.
You asked the Plan to waive the coinsurance for an automatic external defibrillator. You say that you thought that the vest would be fully covered. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 DME and related supplies. You received an automatic defibrillator on December 18, 2020. The total allowed amount is $2,925.60 and 20% of that is $585.12. You received an automatic defibrillator on January 18, 2021. The total allowed amount is $2,925.60 and 20% of that is $585.12.
You received an automatic defibrillator on February 18, 2021. The total allowed amount is $2,925.60 and 20% of that is $585.12. The total amount you owe is: $1,755.36. You have been asked to pay the total coinsurance amount of $1,755.36 for an automatic external defibrillator. An automatic external defibrillator falls within the DME 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 an automatic external defibrillator provided from December 18, 2020, to February 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone scan.

You asked the Plan to pre-approve a bone scan. You say that this bone scan is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met. The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and stated that the QIC did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a bone scan.
The QIC Physician Reviewer determined that the diagnosis was prostate cancer. It was determined that
follow-up imaging is reasonable and necessary. The Plan requested a reopen and notes that prior bone scans
and CT scans revealed no metastatic disease. The Plan agrees that if there had been an abnormal bone scan in
2019, periodic follow-ups would be necessary. However, the bone scan shows there is no metastatic disease.
The Plan is correct in this case. The documentation does not support an abnormal bone scan in 2019, and does
not support that the requested bone scan was medically reasonable and necessary at the time of the request.

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 bone scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve a bone scan.