Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an osteogenesis stimulator for the enrollee.

You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied
your request. The Plan says there is no non-union of bones for over 90 days.

The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs
separated by a minimum of 90 days.

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 stimulator. Our reviewer says that
the requested stimulator is not medically reasonable or necessary. Our physician reviewer found the enrollee
underwent a fusion of the foot on October 14, 2020. Nine months from the time of this surgery as not lapsed.
The elements of the coverage criteria are not satisfied.

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 stimulator have not been met. Therefore, we decided that the Plan does not
have to pre-approve an osteogenesis stimulator for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the retroperitoneal space sonogram (CPT code 76770) performed on February 5, 2021.
You asked the Plan to waive the copayment for the diagnostic radiology service. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a retroperitoneal space sonogram on February 5, 2021. You have been asked to pay 20% coinsurance of the allowed amount for diagnostic radiology services. The allowed
amount is $126.84. The total you owe is $25.37 ($126.84 x 20% = $25.37). 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 retroperitoneal space sonogram (CPT code 76770) performed on February 5, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99291) provided on January 27, 2021,
through February 10, 2021.
You asked the Plan to pay for the office visit. You say that you would like reconsideration because you paid
your copay and the rest should be the responsibility of the Plan. The Plan denied your request. The Plan says
the provider also billed with CPT code 99291 which is not covered when billed by a chiropractor.
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 the office visit (99291) provided on January 27, 2021, through February 10,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation and caries risk assessment and documentation provided on January 4, 2021.

You asked the Plan to pay for the comprehensive periodontal evaluation and caries risk assessment and documentation. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered.

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 pay for the comprehensive periodontal evaluation and caries risk assessment and documentation provided on January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on November 8, 2020.

You asked the Plan to pay for knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf (L1833RT) and addition to lower extremity orthosis, suspension sleeve (L2397). You say that the Plan should pay this claim. The Plan denied your request. The Plan says documentation indicates services are not necessary for treatment of the enrollee's condition.

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 knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf (L1833RT) and Addition to lower extremity orthosis, suspension sleeve (L2397). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf (L1833RT) and Addition to lower extremity orthosis, suspension sleeve (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on November 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe
gingival inflammation (D4346) provided on January 21, 2021.
You asked the Plan to pay for the scaling. You say that you cannot afford to pay for this bill. The Plan denied
your request. The Plan says this service is not a covered benefit under your dental 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 pay for the
scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on January 21,
2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the stress test provided on February 4, 2021.
You asked the Plan to waive the copayment for the stress test. You say that no one told you there would be copayments when the tests were approved. You say that you don't think you should pay. The Plan denied your request. The Plan says you are only responsible for the $150 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 $150 copayment for each advanced imaging service (MRI, CT and PET scans, nuclear medicine and stress tests).
You have been asked to pay a $150 copayment for the stress test. The stress test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the stress test provided on February 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 15, 2020.
You asked the Plan to pay for the services. 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 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 services provided by an out-of-network provider on December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two removable prosthodontic procedures provided on January 22, 2021.

You asked the Plan to pay for the removable prosthodontic procedures. You say that you would like these services to be covered. The Plan denied your request. The Plan says this service is not covered.

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 pay for the two removable prosthodontic procedures provided on January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on January 25, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that this appointment was unnecessary, and you will not pay the copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 a $35 copayment for each in-person specialist visit. 

You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 specialist office visit provided on January 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a transcatheter aortic valve replacement (TAVR) procedure (33361) provided on December 16, 2020.

You asked the Plan to pay for a TAVR procedure. 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 TAVR is covered under Coverage with Evidence Development (CED) for the treatment of symptomatic aortic valve stenosis when furnished according to a Food and Drug Administration (FDA)-approved indication and when the heart team and hospital are participating in a prospective, national, audited registry or for uses that are not expressly listed as an FDA-approved indication when performed within a clinical study that fulfills certain requirements. 

We looked at the file and Medicare rules. The submitted documentation does not show that the facility or enrollee were enrolled in a registry or clinical study that supports coverage for the procedure at issue under CED. Based on this information, we decided that Medicare rules for coverage of a TAVR procedure have not been met. Therefore, we decided that the Plan does not have to pay for a transcatheter aortic valve replacement (TAVR) procedure (33361) provided on December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit (E0745)
provided September 27, 2020.
You asked the Plan to pay for the electronic shock unit. You say that the medical records provided will show
proof of medical necessity. The Plan denied your request. The Plan says the records do not support the service
billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid physician order, proof of delivery, or relevant medical records which
support medical necessity for the supplies provided in this case. Specifically, the documentation did not include
proof of delivery or an itemized shipping/billing invoice to indicate the specific supplies. The record shows that
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided
that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit (E0745) provided
September 27, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Scrambler Therapy.
You asked the Plan to pre-approve the Scrambler Therapy. You say that you have had this therapy before for neuropathy (postherpetic neuralgia) and you are 99% pain free. The Plan denied your request. The Plan says Scrambler Therapy is experimental/investigational and unproven.
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 Scrambler Therapy. Our reviewer says that the requested Scrambler Therapy is not considered experimental/investigational in this case. Our physician reviewer found that the available literature on the proposed therapy is largely limited to small, short term studies, that were not randomized and/or lacked an adequate comparison group. Some of the more recent studies of this technology have not demonstrated a significant benefit of the proposed therapeutic modality when compared to placebo/sham treatment. At the same time there are not currently any professional societies who are recommending the use of this technology for the management of neuropathic pain in any form. Likewise, there remains a need for evidence from well-designed clinical studies to permit conclusion on the overall efficacy of this technology and to determine what, if any, place this has in therapy.
As such at this time this service would be more classified as experimental/investigational and does not meet Medicare criteria for coverage. 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 Scrambler Therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve Scrambler Therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne Liquid CDx testing provided on October
28, 2020.
You asked the Plan to pay for the FoundationOne Liquid CDx testing. The Plan denied your request. The Plan
says this test is not medically necessary.
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 FoundationOne Liquid CDx testing. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found that the enrollee is an 83-year-old male with prostate cancer. FoundationOne
Liquid CDx testing (gene testing) was performed. Based on current evidence regarding this and similar testing,
there was insufficient supportive and high-quality data that suggests this testing method is superior to standard
testing and treatment, or that it leads to a significantly improved outcome overall compared to standard
treatment/testing. Therefore, this request for FoundationOne Liquid CDx testing will be considered not
medically necessary at this time.
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 FoundationOne Liquid CDx testing have not been met. Therefore, we
decided that the Plan does not have to pay for the FoundationOne Liquid CDx testing provided on October 28,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the acupuncture visit provided on February 8, 2021.

You asked the Plan to waive the copayment for the acupuncture visit. You say that you should be reimbursed the full $80. You say you have been fully reimbursed for the same provider and service in the past. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount. The Plan says you have been reimbursed $60.79 and $4.21 for the acupuncture visit.

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 $15 copayment for each Medicare-covered acupuncture visit.

You have been asked to pay a $15 copayment for the acupuncture visit. The acupuncture visit falls within the "Acupuncture for chronic low back pain" benefit category. The record shows you have been reimbursed a total of $65. ($80 - $65 = $15). 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 acupuncture visit provided on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 11, 2021 and March 11, 2021.
You asked the Plan to waive the copayment for the office visits. You say that you won't be able to go back to him because it's too high. The Plan denied your request. The Plan says the copayments 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 $40 copayment for each in-network specialist visit for Medicare-covered benefits.
You have been asked to pay a $40 copayment for each office visit. The total amount you owe is $80 ($40/visit x 2 visits = $80). The office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The office visits were provided at a specialist's office. 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 office visit provided on February 11, 2021 and March 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on December 10, 2020, December 14, 2020, and December 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 drug testing provided on December 10, 2020, December 14, 2020, and December 17, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the chiropractic services to be provided by an out-of-network provider.

You asked the Plan to pre-approve the chiropractic services. You say that this provider is near your home because you have severe back pain and the providers the Plan has referred you to are forty-five (45) minutes from your house. The Plan denied your request. The Plan says the distance to the in-network chiropractor is eighteen (18) miles in Google Maps as it as a 19-minute drive on the freeway.

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 the chiropractic services to be provided by an out-of-network provider.