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

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 7, 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 physician services provided to the enrollee on April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on May 24, 2021.
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says that the Plan does not cover eye refractions.
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.
We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-covered eye condition and not a routine eye exam. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on May 24, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on October 8, 2020.

You asked the Plan to pay for the lab testing. You say that these services were medically necessary and should be paid. The Plan denied your request. The Plan says the enrollee was in a covered Part A SNF stay. As such, payment must be made by the SNF.

The Plan must follow Medicare rules. Medicare rules say that for most Medicare-covered services rendered to a Part A SNF inpatient, payment must be made under arrangements by the SNF and cannot be paid directly by another payer.

In this case, the enrollee was a SNF inpatient from October 5, 2020, through October 31, 2020. These lab tests are not payable by the Plan as must be reimbursed by the SNF in question. Therefore, we decided that the Plan does not have to pay for the lab testing provided on October 8, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and psychotherapy services (CPT code(s): 90836 and 99214) provided on June 21, 2021, by an out-of-network provider.
You asked the Plan to pay for the services. You say that you are using this provider four (4) times a year for almost ten (10) years and never had an issue with not paying. You state the doctor always submits the claim, and they receive reimbursement. The Plan denied your request. The Plan says the services were being paid prior to June 21, 2021, because of the Coronavirus telehealth guidelines services with no enrollee cost-share through the expiration of the New York State (NYS) emergency order. The Plan states services were rendered in office therefore does not qualify for the telehealth coverage. The Plan states this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 office visit and psychotherapy services (CPT
code(s): 90836 and 99214) provided on June 21, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost sharing for the magnetic resonance imaging (MRI) of the brain and the MRI of the spinal canal you had on May 21, 2021.
You asked the Plan to reduce the cost sharing for the two MRIs. You say that you should only have to pay one copayment since these were done at the same facility at the same time and they were the same type of service. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that because the allowed amounts for these two MRIs ($241.19 and $235.81) are less than your copayment obligation, you are responsible for the full allowed amount for each service.
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 diagnostic radiology service.
You have been asked to pay a $250 copayment for the two MRIs. Your Evidence of Coverage states that this copayment applies to each diagnostic radiology service. You had two MRIs, so two copayments apply. 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 reduce the cost sharing for the magnetic resonance imaging (MRI) of the brain and the MRI of the spinal canal you had on May 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed.
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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on July 16, 2020 to July
17, 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 procedure codes 99291 and 99292 are not supported.

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 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes. The definition of code 99292 is critical care,
evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List
separately in addition to code for primary service).

We find that procedure codes 99291 and 99292 are not supported in the medical record. Specifically, there is no documentation of critical care services for the first 30-74 minutes spent on the enrollee to support code 99291 and of each additional 30 minutes to support code 99292. 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 critical care services rendered on July 16, 2020 to July 17, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on November 27, 2020.

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 due to the enrollee's hospice election at the time of service, this claim must be submitted to Original Medicare first.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on November 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare criteria are not met.
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 administrations. Based on this information, we decided that Medicare rules for
coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on May 9,
2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you should not have to
pay this copayment because your ID card doesn't list a copayment for transportation. You stated that the ID
card lists cost sharing for emergency visits, but it is unfair that the card doesn't show the copayment for
ambulance services. The Plan denied your request. The Plan says you were charged this copayment 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 ambulance services.
You have been asked to pay a $250 copayment for the ambulance services. Plans are not required to list every
cost sharing amount on their ID cards because all cost sharing amounts are listed in the Evidence of Coverage
booklet sent to you annually. 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 ambulance services you received on May 9,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a dental filling (D2332) provided on April 8, 2021.

You asked the Plan to pay for a dental filling. You say that it does not seem fair that the benefit is limited to two fillings per year. The Plan denied your request. The Plan says rules for payment have not been met.

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. The Plan covers two dental fillings per calendar year. 

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a dental filling have not been met. Specifically, the Plan has documented that you have already had two covered dental fillings in 2021 prior to the date of service at issue. Therefore, we decided that the Plan does not have to pay for a dental filling (D2332) provided on April 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 19, 2020.

You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on November 5, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on November 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (denosumab) injections.

You asked the Plan to pre-approve the Prolia treatments. You say that this drug would be preferred due to the
enrollee's history of fracture. The Plan denied your request. The Plan says there has been no trial of zoledronic
acid as required.

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 Prolia treatments. Our reviewer says
that the requested drug is not considered reasonable and necessary based on step therapy criteria. Our physician
reviewer found the Plan requires a trial of drug Zoledronic Acid before they will approve the requested
drug. In this case, the patient has not tried and failed the required drug. There is no documentation provided
indicating that the plan's required drug would likely be less effective and/or likely have adverse effects for the
enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the Prolia treatments have not been met. Therefore, we decided that the Plan
does not have to pre-approve Prolia (denosumab) injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided to the enrollee on September 16, 2020.

You asked the Plan to pay for the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device (E0675) to treat peripheral artery disease is not eligible for reimbursement. 

The requested device (E0675) and accessory (E0673) are statutorily not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we
decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided to the enrollee on September 16, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on September 8,
2020.

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 due to the enrollee's hospice election at the time of service, this claim must be submitted
to Original Medicare first.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for physician services provided to the enrollee on September 8,
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit injections.
You asked the Plan to pre-approve the Retacrit injections. You say that this is medically indicated. The Plan denied your request. The Plan says the enrollee's lab values are not such that this treatment would be considered necessary at this time.
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 the Retacrit injections. Our reviewer says that the requested treatment with Retacrit is not medically reasonable and necessary. Our physician reviewer found the accepted use of this drug requires recent Hemoglobin (Hgb) level less than 10.0 g/dL or Hematocrit (HCT) less than 30%. Based on the available information, the enrollee does not meet these requirements. The review has determined that the documentation does not support that the Retacrit is medically reasonable and necessary for the patient. The documentation does not support that the Retacrit is safe and effective for the patient. 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 Retacrit injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) for tooth #7.

You asked the Plan to pre-approve a custom fabricated abutment. You say that you do not understand why this
service is being denied. The Plan denied your request. The Plan says this service is not covered by your dental
benefit.

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 a
custom fabricated abutment (D6057) for tooth #7.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the x-ray of the cervical spine and x-ray of 
the shoulder you had on February 5, 2021. 
 
You asked the Plan to waive the copayments for the two x-rays. You say that you shouldn't have to pay another 
copayment for these services. The Plan denied your request. The Plan says you were charged these copayments 
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 $30 
copayment for each x-ray service.  
 
You have been asked to pay a $30 copayment for each of the x-rays. This is a per-service copayment, so you 
were appropriately charged twice. 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 copayments for the x-ray of the 
cervical spine and x-ray of the shoulder you had on February 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dilation of the eustachian tube. 
 
You asked the Plan to pre-approve the eustachian tube dilation. You say that you believe that this procedure 
should be allowed so that the TM tubes do not have to be replaced. The Plan denied your request. The Plan 
says this is not a medically necessary service at this time. 
 
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 eustachian tube dilation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a 36-year-old with a diagnosis of unspecified bilateral 
eustachian tube disorder. The enrollee has had multiple sets of tympanostomy (TM) tubes for eustachian tube 
dysfunction. On 8/13/21, the enrollee complained of itching of his bilateral ears. The enrollee denied any pain. 
Exam showed that the TMs were clear with normal mobility. It is noted that both TMs were retracted. It was 
hoped that eustachian tube dilation would avoid putting tubes back in his ears. The enrollee has clear TMs with normal mobility. The service is not indicated for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the eustachian tube dilation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve dilation of the eustachian tube.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services received on March 15, 2021. 
 
You asked the Plan to pay for the services. You say that this should not be denied. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services received on March 15, 2021.