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

We decided that the Plan does not have to pay for the lab services provided on November 12, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are not covered for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The lab services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 2, 2020. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified. 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 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on January 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia syringes.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B under the circumstances. The Plan also says that they have approved coverage under the enrollee's Medicare Part D prescription drug benefits.
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 Prolia syringes.
Benefits for 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) knee orthosis (L1833) and suspension sleeve (L2397) provided November 4, 2019.
You asked the Plan to pay for the orthoses. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) knee orthosis (L1833) and suspension sleeve (L2397) provided November 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee required minimal assistance with walking, transfers, and activities of daily living. The documentation does not support that there are significant, or complex medical/nursing issues that need to be addressed in the IRF. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that the enrollee cannot perform some activities of daily living on her own. The Plan denied your request. The Plan says the denial of authorization for SNF service is correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is improving with outpatient therapy and ambulating more than 100 feet. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs can be provided at a lower level of care such as home, assisted living, or long-term care facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on January 30, 2020.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you had not seen a dentist in four years, and you requested to have a checkup, x-ray, and cleaning. You also say that they did the x-ray and told you that you need a tooth removed. 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. The only x-rays that are covered by your plan are bitewing x-rays. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on January 30, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvebreast reconstruction revision (19380) and a graft (20926).You asked the Plan to pre-approvethe revision and graft. You say that you would like reconsideration because you experience pain and discomfort at the surgery site.The Plan denied your request. The Plan says that this procedure is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the revision and graft. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found you have evidence of complications following your original surgery so reasonable attempts to correct complications from a medically necessary reconstruction satisfy Medicare criteria.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 revision and graft have been met.Therefore, we decided that the Plan has to pre-approvebreast reconstruction revision (19380) and a graft (20926).If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a primary care office visit provided on February 11, 2020.You asked the Plan to waive the copayment for office visit. You say that you thought this was a wellness examination and feel this was coded incorrectly.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 copayment for primary care office visit. The record shows thatthis visit addressed multiple non-routine issues, therefore a diagnostic office visit with applicable copayment was billed on this claim.You have been asked to pay $20 copayment for office visit. 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 fora primary care office visit provided on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Superion Vertiflex procedure You asked the Plan to pre-approve the Superion Vertiflex procedure. You say that you would like reconsideration because this procedure is medically necessary.The Plan denied your request. The Plan says there is not enough evidence to show that this procedure is safe and helpful 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 Superion Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer remains experimental for use in the spine and more research is needed to show safety and efficacy.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 Superion Vertiflex procedure have not been met.Therefore, we decided that the Plan does not have to pre-approve Superion Vertiflex procedure
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on January 18, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you were brought to urgent care not
the emergency room. You say that you shouldn't have to pay for the emergency room. The Plan denied your
request. The Plan says the copayment 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 $90
copayment for each emergency room visit.
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care"
benefit category. The records show that you were treated in the ER. 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 ER visit provided on January 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral exam (D0150) provided February 14, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing the denial of the claim and have provided the billing statement. The Plan denied your request. The Plan says this exceeds the benefit frequency limitation
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. This service is allowed once every 3 years. The records show this service was provided September 17, 2019. 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 comprehensive oral exam (D0150) provided February 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond of a crown provided on February 19, 2020.
You asked the Plan to pay for the re-cement or re-bond of a crown. You say that you do not agree with this denial. 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 re-cement or re-bond of a crown provided on February 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 additional physical therapy visits.
You asked the Plan to pre-approve additional physical therapy visits. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically
necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 additional physical therapy visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found you were independent with transfers and activities of
daily living. Home exercises have been discussed/implemented. Endurance remains an issue. The
documentation does not support that the services are required to establish, design and/or deliver a program to
maintain your current condition or to prevent or slow further deterioration. The documentation does not support
that residual deficits could not be addressed via a home exercise program. Therefore, you do not meet criteria
for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve 2 additional physical therapy visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transport (A0425) provided January 21, 2020.You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct cost-sharing was applied.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 $225 copayment for ambulance services. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran ambulance transport (A0425) provided January 21, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing and androgen receptor (AR) gene
analysis provided on August 15, 2019.
You asked the Plan to pay for genetic tests. You say that these tests were ordered by the enrollee's treating
physician to determine the optimal treatment. The Plan denied your request. The Plan says the denial of
payment for these services is correct, because Guardant360 testing was not billed using the appropriate coding
and AR gene analysis with procedure code 81173 was excluded from coverage.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 must be billed using procedure
code 81479. Medicare rules also say that procedure code 81173 was an excluding testing code for date of
service August 15, 2019.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of genetic tests have not been met. Therefore, we decided that the Plan does not have to pay for
Guardant360 testing and androgen receptor (AR) gene analysis provided on August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the TDAP vaccine you received on October 30, 2019. You asked the Plan to pay for the vaccine. You say that you were not aware that this would not be covered. The Plan denied your request. The Plan says this is not covered under your Part B plan. In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the TDAP vaccine you received on October 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit rendered on July 9, 2019.
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 code 99348 is 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 99348 is established patient home visit, typically 25 minutes. We find that CPT code 99348 is not supported in the medical record. Specifically, the file shows that the services were rendered by a CNA and no physician was present. 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 home visit rendered on July 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the headgear (A7035) and continuous airway pressure (CPAP) device provided on February 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the CPAP and headgear. You say that the plan does not give options to order from another company and you should be allowed to have options to get service elsewhere when a company the insurance uses gives poor service The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. This provider is not a certified Medicare provider.
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 has network providers available who can provide 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 headgear (A7035) and continuous airway pressure (CPAP) device provided on February 4, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power wheelchairpower seat elevation feature.You asked the Plan to pre-approvea power seat elevation feature (E2300). You say that you need a Group 3 power wheelchair, accessories, and a power seat elevation feature.The Plan denied your request. The Plan says a power seat elevation feature is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  A power seat elevation feature does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea power wheelchairpower seat elevation feature.