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

We decided that the Plan has to pay forthe cold therapy pump and pad provided on June 5, 2020.You asked the Plan to pay fora fluid circulating cold pad with pump, any type.You say that the Plan should pay this claim.The Plan denied your request. The Plan says that a fluid circulating cold pad with pump is not covered by Medicare.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.You were referred for a fluid circulating cold pad with pump, any typeby a contract provider. The file does not show that the Plan provided notice that a fluid circulating cold pad with pump, any typewould not be covered. Under Medicare rules, this means a fluid circulating cold pad with pump, any typeis considered approved by the Plan.Therefore, we decided that the Plan has to pay forthe cold therapy pump and pad provided on June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the oral exam (D0120), the cleaning
(D1110), the bitewing x-rays (D0274), and the unspecified preventive dental service (D1999) provided on
August 19, 2020.
You asked the Plan to pay the in network rate for the dental services. You say that you have been going to see
this dental provider for years. You say that the services should have been processed at the in network rate. The
Plan denied your request. The Plan says the dental provider in this case is not a network provider. The Plan also
says the unspecified preventive dental service is not listed as a covered service.
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 provider in this case is not a
network provider. The record shows that the provider has not be contracted with the Plan since February 2020.
There is a 50% coinsurance for preventive dental services that you receive out of network. This is a contractual
obligation you agreed to when you enrolled in the Plan's dental coverage. Out of network providers are also
able to bill you for any amount greater than the payment made by the Plan to the provider. Additionally, the
unspecified preventive dental service is not among those covered under this benefit. Therefore, we decided that
the Plan does not have to pay the in network rate for the oral exam (D0120), the cleaning (D1110), the bitewing
x-rays (D0274), and the unspecified preventive dental service (D1999) provided on August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99201) provided on July 22, 2020.You asked the Plan to pay foran office visit. You say that you were referred to this provider by your dentist.The Plan denied your request. The Plan says this provider has opted out of Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay forthe office visit (99201) provided on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by an out-of-network (OON) provider.

You asked the Plan to pay for physician services. You say that these services were provided in good faith.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the rendering provider and rendering facility are out-of-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 physician services provided, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.  

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient appears to have not attempted weaning and the potential for such is not clear. Additional short term acute care services are needed and can safely be completed at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

e decided that the Plan does not have to pre-approve electric massage chair (A9270).


You asked the Plan to pre-approve electric massage chair. You say that you are requesting an appeal for an electric massage chair since your health is being affected.The Plan denied your request. The Plan says this item is not covered.

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 electric massage chair (A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatmentwith an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have notbeen met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) services to be provided by an out of network (OON) provider. 

You asked the Plan to pre-approve IRF services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided to the enrollee by a network 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 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 inpatient rehabilitation facility (IRF) services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for maxillary partial denture - cast metal
framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) provided
on June 29, 2020.
You asked the Plan to waive the copayment for partial denture. You say that the service was medically
necessary. The Plan denied your request. The Plan says the member is eligible for this service, however, the
member is responsible for the cost share.
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 with a
$715 patient charge.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services has a
cost share. Therefore, we decided that the Plan does not have to waive the copayment for maxillary partial
denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)
(D5213) provided on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for payment for a tele health distant site service (G2025) provided.

You asked the Plan to pay for the payment for a tele health distant site service. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this service has not been billed correctly.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 


We find that CPT code G2025 is not supported in the record. Specifically, per Medicare guidance, this code has not been billed with the required modifier. Based on this information, we decided that Medicare rules for coverage of the payment for a tele health distant site service have not been met.Therefore, we decided that the Plan does not have to pay for payment for a tele health distant site service (G2025) provided.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health skilled nursing visits provided on April 7, 2020 and April 13, 2020 billed with code G0299.
You asked the Plan to pay for the home health visits. You say that these should be paid. The Plan denied your request. The Plan says the services were not billed on the correct claim form for home health services.
The Plan must follow Medicare rules. Medicare rules say that home health agencies must bill for services on an institutional claim form. The code G0299 is a home health service which can only be paid when submitted on an institutional claim form with a valid Type of Bill. Therefore, we decided that the Plan does not have to pay for the home health skilled nursing visits provided on April 7, 2020 and April 13, 2020 billed with code G0299.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pay  forthe  knee orthosis  and suspension  sleeve  provided  on July  15, 2020.You asked the  Plan to pay  forthe  services  provided.  You  say that the  enrollee  cannot  ambulate  without  pain and discomfort.The  Plan  denied  your  request.  The  Plan  says without  a face-to-face  encounter,  the ordering physician  could  not gather  the  information  associated  with  the supplies  ordered.The  Plan  must  follow  Medicare  rules.  The  rules  state the  medical  record must  contain  sufficient  documentation of theenrollee'smedical  condition. We looked  at the  file  and the  rules.  The  documentation  provided  does not  indicate  that  the  treating  physician had a face-to-face  encounter  with  the  enrollee.  Based on this  information,  wedecided  that  the Medicare  rules for  coverage  have  not been met. Therefore,  we decided  that  the Plan  does not  have to pay forthe  knee orthosis and suspension  sleeve  provided  on July  15, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nasal mask and headgear provided on May 1, 2020.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says Medicare does not cover services that are not performed by a Medicare-certified provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you receive your care from a provider who is eligible to provide services under Original Medicare.The providersin thiscase arenot eligible to provide services under Original Medicare.The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for the servicesat issue.Therefore, we decided that the Plan does not have topay forthe nasal mask and headgear provided on May 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea pneumatic compression device (E0652).You asked the Plan to providea pneumatic compression device. You say that the enrollee needs a pneumatic compression device to manage lower extremity lymphedema. The Plan denied your request. The Plan says the enrolleehas not had a trial of a basic pneumatic compression device The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial ofconservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this informationwe decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to providea pneumatic compression device (E0652)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the risk assessment panel provided on May 6, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that LCD L36523 denies coverage for all CV risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. Per LCD L36523, the requested risk assessment panel is non-covered. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the risk assessment panel provided on May 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean interspinous spacer placement (22869).You asked the Plan to pre-approvethe spacer placement. You say that the procedure is medically necessary.The Plan denied your request. The Plan says rules for coverage have not been met.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 spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested Vertiflex spacer device is considered experimental at this time. 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 spacer placement have not been met.Therefore, we decided that the Plan does not have to pre-approvean interspinous spacer placement (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forre-cement or re-bond fixed partial denture (D6930).You asked the Plan to pay forre-cement or re-bond fixed partial denture. You say that the service was medically necessary.The Plan denied your request. The Plan says the service rendered is not a covered 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 forre-cement or re-bond fixed partial denture (D6930).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvefacet joint injections for the enrollee.You asked the Planto pre-approvethe injections. You say that this is medically necessary.The Plandenied your request. The Plansaysrepeat injections without appropriate response has not been proven to be effective in improving 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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found on 9/22/2020 the enrollee had previously undergone right L3/4, L4/5 and L5/S1 facet injections. The enrollee reported 80% pain relief which lasted one week.  This request is for repeat injections bilaterally at L4/L5, and L5/S1. The provided medical records do not document that the enrollee has satisfied the requirements.  Therefore, this procedure is not medically necessary and reasonable.
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 injections have not been met.Therefore, we decided that the Plandoes not haveto pre-approvefacet joint injections for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forspecialist services provided on September 3, 2020 by an out of network (OON)provider.You asked the Plan to pay forspecialist services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available for these services.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 Plandid 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 forspecialist services provided on September 3, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy, core buildup, and a crown from a
non-contracted provider.
You asked the Plan to pre-approve the endodontic therapy, core buildup, and crown to be provided out of
network. The Plan denied your request. The Plan says services provided by an out of network provider 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 coverage of these benefits is
limited to when the services are provided within the dental vendor network. Therefore, we decided that the Plan
does not have to pre-approve endodontic therapy, core buildup, and a crown from a non-contracted provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe diagnostic mammogram provided on August 20, 2020.You asked the Planto waive the copayment forthe diagnostic mammogram. You say that you were informed this was a preventive test and you wouldn't have to pay anything.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 $50 copayment for each Medicare-covered x-ray at an in-network outpatient hospital facility. 
You have been asked to pay a $50 copayment for the diagnostic mammogram. The diagnostic mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that a diagnostic mammogram was performed. 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 forthe diagnostic mammogram provided on August 20, 2020.