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

We decided that the Plan does not have to pay for the electrodes and the replacement batteries provided on December 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the electrodes and replacement batteries. You say that you are appealing the denial. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for electrodes and replacement batteries provided on December 3, 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 topical application of fluoride varnish (D1206) provided on November 4, 2020.

You asked the Plan to pay for the fluoride. You say that you were told that services from this provider were pre-approved and would be covered, and you do not understand why they are 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 pay for the topical application of fluoride varnish (D1206) provided on November 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing.
You asked the Plan to pre-approve genetic testing. You say that the enrollee's brother is currently being treated
for prostate cancer, and this testing is pertinent to the enrollee's health. The Plan denied your request. The Plan
says the enrollee has no signs or symptoms of cancer and BRCA testing of an unaffected individual or family
member is not a covered benefit.
The Plan follows Medicare rules. Medicare rules state that BRCA1 and BRCA2 genetic testing is considered
medically necessary for enrollees with a current diagnosis or personal history of certain cancers who meet
certain criteria.
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 genetic testing. Our reviewer says that
the enrollee does not meet the Medicare criteria for BRCA testing. Our physician reviewer found the enrollee's
brother has prostate cancer; however, the enrollee has not been diagnosed with cancer nor has a history of
cancer according to the records provided.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not
have to pre-approve BRCA1 and BRCA2 genetic testing.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on September 2, 2020.

You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the documentation submitted on appeal consists of duplicates of medical documents previously reviewed.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical records to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sacroplasty.
You asked the Plan to pay for sacroplasty. 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 follows Medicare rules. Medicare rules say that sacroplasty is only covered for certain indications. 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 sacroplasty. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found treatment of sacrum is not a covered indication under the local coverage criteria. The elements of the coverage rule are not satisfied. Therefore, the enrollee does 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 sacroplasty have not been met. Therefore, we decided that the Plan does not have to pay for sacroplasty.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the heart (75571).
You asked the Plan to pre-approve the CT scan of the heart. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says the test is requested for screening purposes and it is not covered.
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 test at issue in this appeal, the CT scan of the heart, is being requested solely for screening purposes. No clinical documentation was provided to support the request. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve Computed Tomography (CT) of the heart (75571).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0427, A0425) received January 1, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you had no choice but to call the ambulance. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $275 copayment for Ambulance Services. You have been asked to pay a $275 copayment for the ambulance transportation. The ambulance transportation 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 for the ambulance transportation (A0427, A0425) received January 1, 2021.
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 IRF care is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says rules for IRF care have not been met and the enrollee
can receive care in a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve 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 that the patient was admitted to an acute care hospital for surgical treatment of a
subdural hematoma and seizures. Medical conditions are stable. There are no complex nursing or rehabilitation
needs. In this case, the patient does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require
physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. In conclusion, there is not a
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from October 22, 2020, to December 22, 2020.

You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you were told that all copayments were waived due to COVID-19 and disagree with the charges. 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 a $30 copayment for outpatient rehabilitation services.

You received outpatient rehabilitation services from October 22, 2020, to December 22, 2020, for a total of 10 visits. Outpatient rehabilitation services are not included in the COVID-19 copayment waiver. Therefore, you are responsible to pay a $30 copayment per each visit. The total amount you owe is: $30 (copayment) x 10 (outpatient rehabilitation visits) = $300. 

You have been asked to pay the total copayment amount of $300 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 copayments for outpatient rehabilitation services provided from October 22, 2020, to December 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three resin-based composites provided on December 7,
2020.

You asked the Plan to pay for the resin-based composites. You say that you would like the Plan to cover 80%
of these services, leaving you responsible for 20%. 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 three
resin-based composites provided on December 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography provided on November 18, 2020 by an out of network provider.

You asked the Plan to pay for needle electromyography (95867, 95870). You say that you would like the Plan to pay this claim at the in-network rate. The Plan denied your request. The Plan says you did not request prior authorization for the non-urgent procedures.

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. 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 needle electromyography provided on November 18, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on August 12, 2020 and repair of hearing aids provided on December 15, 2020.

You asked the Plan to reimburse you for the hearing aids and repair of hearing aids. The Plan denied your request. The Plan says hearing aids ordered through providers other than the Plan's provider are not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only provided by the Plan's hearing aid provider. 

We looked at the file, and the Plan's rules. The file shows that the hearing aids and the repair services were not provided by the Plan's hearing aid provider. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on August 12, 2020 and repair of hearing aids provided on December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis,
problem focused limited oral evaluation, first intraoral periapical x-ray, and re-cement or re-bond crown
provided on November 23, 2020, and December 8, 2020, by a Medicare opt-out provider.

You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis, problem focused
limited oral evaluation, first intraoral periapical x-ray, and re-cement or re-bond crown. You say that you
would like to appeal these services because you have been reimbursed in the past. The Plan denied your
request. The Plan says these services were rendered by a privately contracted provider.

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
covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the
Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis, problem focused
limited oral evaluation, first intraoral periapical x-ray, and re-cement or re-bond crown provided on November
23, 2020, and December 8, 2020, by a Medicare opt-out provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
You asked the Plan to pre-approve a portable oxygen concentrator. You say that it is not safe for your current equipment to be used while traveling. The Plan denied your request. The Plan says the equipment you currently have is meeting your medical needs.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. In this case, your provider has specifically mentioned that this will be used in the community and you have mentioned it is necessary for you to travel. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis provided from October 2, 2020, through October 30, 2020.
You asked the Plan to waive the coinsurance for the dialysis. You say that health insurance should take care of the payment. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare-covered benefits for outpatient dialysis treatments.
You have been asked to pay $57, which is 20% of the allowed amount for each dialysis treatment. The total amount you owe is $741 ($57/treatment x 13 treatments = $741). Dialysis falls within the "Services to Treat Kidney Disease" 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 dialysis provided from October 2, 2020, through October 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the prophylaxis (D1110) received March 30, 2021 from the non-participating provider.

You asked the Plan to pay an additional amount for the cleaning. You say that you were told by the dental office that they participate with the Plan. The Plan denied your request. The Plan says the provider does not participate with the 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 payment is in excess of what is covered under this benefit. The Plan agreed to pay 100% of the allowed amount for the cleaning. The Plan contract states that you are responsible for any amount over and above the allowed amount that is billed by a non-participating provider. Therefore, we decided that the Plan does not have to pay an additional amount for the prophylaxis (D1110) received March 30, 2021 from the non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond crown provided on February 15, 2021.
You asked the Plan to pay for the re-cement or re-bond crown. You say that your EOC states you would only be responsible for a 55% coinsurance for the recementation. The Plan denied your request. The Plan says this service is not a covered benefit. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits or provider eligibility.
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 record shows that the Plan offers an Optional Supplemental Benefit (OSB) for an extra charge each month, in which the recementation is covered at 55% provided out-of-network. The record does not show that you were enrolled in the OSB at the time of this service. Therefore, we decided that the Plan does not have to pay for the re-cement or re-bond crown provided on February 15, 2021.
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 the service is medically necessary. The Plan denied
your request. The Plan says the service is not medically necessary or reasonable.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve 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 patient does not require treatment by multiple therapies and there are no complex
nursing or rehabilitation needs.

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. Specifically, medically necessary services can be
obtained at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we
decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and
services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro orthotic device.
You asked the Plan to pre-approve the requested device. You say that the enrollee requires the device to restore elbow and hand function. The Plan denied your request. The Plan says there is a lack of clinical evidence demonstrating an impact on improved health outcomes.
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 requested device. Our physician reviewer found that at this time the requested robotic orthosis is not proven to be more beneficial for treatment of the enrollee's medical condition or function of hemiparesis after stroke than any available standard therapy. The device is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. It is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the device will improve the long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long-term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. Therefore, the requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member.
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 requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro orthotic device.