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

We decided that the Plan does not have to waive the copayment for the Esophagogastroduodenoscopy (EGD) with biopsy (43239) provided on November 21, 2019.You asked the Plan to waive the copayment for the EGD with biopsy. You say that you feel the enrollee should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says the enrollee received outpatient surgery in an ambulatory surgical center on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per the enrollee's contract with the Plan.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 copayment for Outpatient surgery. We looked at the file, the Plan's contract and Medicare rules. The file shows the enrollee received an EGD with biopsy at an ambulatory surgical center on November 21, 2019. The enrollee has been asked to pay a $300 copayment for the EGD with biopsy. The EGD with biopsy falls within the Outpatient surgery benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the Esophagogastroduodenoscopy (EGD) with biopsy (43239) provided on November 21, 2019.Your complaint about the Plan providing the incorrect cost share information is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on December 26, 2019.You asked the Plan to payforthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the provided services were neither emergent nor urgent and prior authorization was not obtained to provide out of network care.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  We looked at thefile and Medicare rules. The file does not show that these services were provided due to an unforeseen illness or condition. The file does not show that the services provided were emergent or urgent. The file does not show that the Plan pre-approved theseservices. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stellate ganglion nerve block.You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has post-traumatic stress disorder (PTSD), severe anxiety, fibromyalgia, and severe fatigue. There is no definitive study to support that the use of a stellate ganglion nerve block helps improve mental health issues. The services are not the standard of care and are considered experimental/investigational in nature. The services are therefore not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a stellate ganglion nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine vision services rendered.
You asked the Plan to pay for these services. You say that prior authorization was not required. The Plan
denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and
eyewear.
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we
decided that the Plan does not have to pay for the routine vision services rendered.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance.
You asked the Plan to pay for the periodontal maintenance. You say that you were told that the treating provider was on your plan. The Plan denied your request. The Plan says the Plan says that 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 periodontal maintenance.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs are custodial.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) services rendered on April 8, 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 the records do not support the billing of codes 95813 and 95955.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 95813 is electroencephalogram (EEG) extended monitoring; greater than 1 hour. The definition of code 95955 is electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery).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 these services. Our reviewer says that the records do not support the billing of codes 95813 and 95955. Our physician reviewer found the submitted records do not support that CPT codes 95813 and 95955 were distinct separately identifiable procedures that were performed on April 8, 2019. These codes has a bundled relationship with code G0453, which was approved for this date of service. Codes 95813 and 9599 are not eligible for separate reimbursement. We looked at this physician's review, the file, and Medicare rules. 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 electroencephalogram (EEG) services rendered on April 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve exercise equipment (A9300).You asked the Plan to pre-approve exercise equipment. You say that the equipment is necessary.The Plan denied your request. The Plan says the item is not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal 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-approve exercise equipment (A9300)
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the cervical collar provided to the enrollee on October 15, 2019.You asked the Plan to pay forthe cervical collar. The Plan denied your request. The Plan says that that the billed services were not supported.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 the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the cervical collar. Our reviewer says that the cervical collar is considered medically reasonable and necessary in this case. The enrollee was evaluated on 8/19/19 for hospital follow-up. The enrollee reported that hersoft neck brace was removed when she was evaluated, and was lost in the hospital. It is documented that the enrollee has cervical spondylosis with radiculopathy and she asked that the brace be replaced, as it helps her neck pain. The enrollee had procedures on her neck in 2017 and 2018. On 10/10/19, the enrollee's physician ordered a cervical collar, L0174. Our physician reviewer found that the enrollee's condition meets criteria for coverage of the cervical collar.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 cervical collar have been met.Therefore, we decided that the Plan has to pay forthe cervical collar provided to the enrollee on October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services coded 82947, 84132, 84295, 85014, 96374 and 96375 provided from January 23, 2019 to January 25, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were not billed correctly.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes 82947, 84132, 84295, 85014, 96374 and 96375 are not supported in the medical record. Specifically, these codes were billed without an appropriate modifier. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory services coded 82947, 84132, 84295, 85014, 96374 and 96375 provided from January 23, 2019 to January 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe flu shot you received on November 20, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that you were not told the clinic was not contracted with your plan.The Plan denied your request. The Plan says the out-of-network services were provided without prior authorization.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 services at issue in this appeal. The Plan did not pre-approve the services. 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 forthe flu shot you received on November 20, 2019 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the incontinence supplies provided to the enrollee ny an out of network (OON) provider.
You asked the Plan to pay for the incontinence supplies. The Plan denied your request. The Plan says that the supplies could be provided in network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 incontinence supplies provided to the enrollee by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan injections.You asked the Plan to pre-approve the requested service. You say that the enrollee's osteoarthritis will benefit greatly from Hyalgan visco supplementation.The Plan denied your request. The Plan says the enrollee has not had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc. 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 requested service. Our physician reviewer found that the enrollee has primary osteoarthritis of the knees. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. There is no documentation that the enrollee has tried and failed the required drugs. The documentation does not support that Monovisc and Orthovisc would likely be less effective, or would likely have adverse effects for the enrollee in this case.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 service have not been met.Therefore, we decided that the Plan does not have to pre-approve Hyalgan injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records for the billed services.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray and consultation provided on October 23, 2019.You asked the Plan to pay for the panoramic x-ray and consultation. You say that these services were needed due to medication prescribed to you to treat your prostate cancer.The Plan denied your request. The Plan says these services are not covered benefits and were performed by an opt out provider.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay for the panoramic x-ray and consultation provided on October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation, prophylaxis, and resin-based composite provided by an OON provider on November 11, 2019 and November 20, 2019.You asked the Plan to pay forthe periodic oral evaluation, prophylaxis, and resin-based composite. You say that nowhere in your contract does it state that you should go to one of the Plan providers.The Plan denied your request. The Plan says the treating provider is out-of-network with your plan. The Plan also says that you must receive care from an in-network 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 received out-of-network.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation, prophylaxis, and resin-based composite provided by an OON provider on November 11, 2019 and November 20, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the services are an extension of the initial visit. The Plan denied your request. The Plan says there is no network deficiency for the services, and alternate network providers were found.
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 ordering provider is also not a network provider with the Plan. The Plan has network providers available who can provide 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 the lab services provided on September 6, 2019 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 rebase of the complete upper denture (D5710) and the rebase of the complete lower denture (D5711) provided on January 16, 2020.You asked the Plan to pay for the dental services. You say that you will not need any further dental services in the future. You also say that any amount of payment would be appreciated as you are on a fixed income.The Plan denied your request. The Plan says the rebase of a complete denture is not a covered service. The Plan also says any services not listed 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 denture rebase is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the rebase of the complete upper denture (D5710) and the rebase of the complete lower denture (D5711) provided on January 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.You asked the Plan to pre-approve SNF services. You say that the care needed is limited at the enrollee's assisted living facility.The Plan denied your request. The Plan says the enrollee's needs are custodial.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 services. Our physician reviewer found that from a nursing perspective, the enrollee had stable vital signs, and was treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at contact guard to minimal assist with functional mobility. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis.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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Ozone CPAP sanitizer for the enrollee.
You asked the Plan to pre-approve these services. You say that it is recommended the enrollee use this machine. The Plan denied your request. The Plan says that Medicare does not cover routine cleaning of equipment, nor does it cover hygienic devices as they are not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal 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-approve an Ozone CPAP sanitizer for the enrollee.