Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe topical application of fluoride varnish provided on December 10, 2019.You asked the Plan to pay forthe topical application of fluoride varnish. You say that a Plan representative provided you with a list of dentists that were in-network with your plan. You also say you called and made an appointment with this provider because you were told they were in-network.The Plan denied your request. The Plan says this service 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 forthe topical application of fluoride varnish provided on December 10, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvehome health skilled nursing visits for the enrollee.You asked the Planto pre-approvethe visits. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee is now medically stable, and doesn't have any further skilled nursing needs.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.A doctor must certify the need for home health care services.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 visits. Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found the records do not show that additional skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The enrollee has had medical condition education and management and does not have complex wound care or other SN need.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 visits have not been met.Therefore, we decided that the Plandoes not haveto pre-approvehome health skilled nursing visits for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.You asked the Plan to pre-approve a shower chair. You say that you are having a hard time taking showers so you asked your doctor to request authorization for the shower chair. You say that you have pain while moving around and you are afraid that an accident may occur while you are in the shower. You stated that you do not believe the Plan is helping you out at all and asked the Plan to reconsider their denial because you really need the requested shower chair.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays and comprehensive oral evaluation provided on November 12, 2019 by an OON provider.
You asked the Plan to pay for the complete series of intraoral x-rays and comprehensive oral evaluation. You say that you needed to start the service immediately because your removable teeth had broken. You also say that you were referred by your primary care physician. The Plan denied your request. The Plan says the services were rendered by an OON provider without prior authorization. The Plan also says that you self-directed to this 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 OON. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays and comprehensive oral evaluation provided on November 12, 2019 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on February 4, 2020.You asked the Plan to waive the copayment forthe laboratory tests. You say that your PCP never explained the difference in cost by location. You say that you shouldn't have to pay this.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 $40 copayment for lab services at an outpatient hospital. You have been asked to pay a $40 copayment for the laboratory tests. The laboratory tests fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forlaboratory tests provided on February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that you are experiencing ambulation and balance difficulties.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement power wheelchair.
You asked the Plan to pre-approve a Group 2 power wheelchair. You say that the enrollee needs a new power wheelchair because parts are not available for the current power wheelchair. The Plan denied your request. The Plan says there is no documentation the enrollee's current power wheelchair is not meeting the enrollee's needs and batteries are available.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee has a power wheelchair. The power wheelchair serves the same purpose as a Group 2 power wheelchair at issue. There is no physician documentation supporting medical necessity for a new power wheelchair. Therefore, we decided that the Plan does not have to pre-approve a replacement power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve COOLIEF radiofrequency ablation of the sacroiliac joint.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary for the pain. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of your health problem.
The Plan must follow Medicare rules. Medicare rules say that cooled radiofrequency ablation is not a covered service. 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 procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the request for Coolief Radiofrequency ablation is a non-covered service. COOLIEF radiofrequency ablation of the sacroiliac joint is not medically reasonable or 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 the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve COOLIEF radiofrequency ablation of the sacroiliac joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a three month continuation of CPAP.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says continued CPAP use is covered when documented compliance is noted.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the compliance data does not meet the minimum usage criteria of at least four hours a day, for at least
70% of days. You have not used the device for four hours or more.

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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a three month continuation of CPAP.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on November 26, 2019.
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
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 genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on November 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe catheter provided on March 2, 2020.You asked the Plan to waive the coinsurance forthe catheter. You say that you are being overcharged for the catheter.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for in-network prosthetics provider. You have been asked to pay $148.68 which is 20% of the allowed amount for the catheter. The allowed amount is $743.40. ($743.40 x 20% = $148.68). The catheter falls within the "Prosthetic devices and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance forthe catheter provided on March 2, 2020.Your complaint that the billing is fraudulent 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a power mobility device.
You asked the Plan to provide a power mobility device. You say that the enrollee needs a power mobility
device. The Plan denied your request. The Plan says the enrollee's mobility is improved by a rollator.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
The Power Mobility Device Evaluation shows that the enrollee's condition can be improved by a walker. This
means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does
not have to provide a power mobility device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services for fracture treatment (25575) provided on July 8, 2019. You asked the Plan to pay for surgical assistant services. You say that this should be covered. The Plan denied your request. The Plan says these services are not covered when performed by an RNFA. The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services for fracture treatment (25575) provided by an RNFA on July 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network hearing provider.
You asked the Plan to pre-approve these services. You say that you have seen this provider in the past. The Plan denied your request. The Plan says the services are only covered from the plan approved provider.
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 covers hearing aid services from the plan approved provider only.
We looked at the file and the Plan's rules. The file shows that you are requesting services from a provider who is not the plan approved provider for hearing aid services. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network hearing provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral x-rays (D0230, D0220) provided November 6, 2019. You asked the Plan to pay for intraoral x-rays. You say that the services should be covered. The Plan denied your request. The Plan says Intraoral x-rays are 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 for intraoral x-rays (D0230, D0220) provided November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on February 26, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 medical services provided to the enrollee by an out-of-network provider on February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
You asked the Plan to pre-approve an automatic blood pressure monitor. You say that you have bad veins and hypertension. The Plan denied your request. The Plan says that this item is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded 80307, G0481, and G0480 provided from September 25, 2019 to December 17, 2019.You asked the Plan to pay forthe drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.Wefind that CPT codes 80307, G0481, and G0480 are not supported in the medical record. Specifically, the documentation did not include a physician order/lab requisition form or medical records stating exactly what tests were to be performed. Also, the placeof service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided thatthe Plan does not have to pay forthe drug testing coded 80307, G0481, and G0480 provided from September 25, 2019 to December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency anesthesia services rendered on January 18, 2020.
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 99140 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. The provider billed procedure code 99140. This code has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency anesthesia services rendered on January 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve5 fractions of stereotactic body radiation therapy (SBRT). You asked the Plan to pre-approve5 fractions of SBRT. You say that the service is necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 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 5 fractions of SBRT. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found while SBRT for widespread disease (which is the case in this enrollee) can perhaps be considered in some selected enrollees, there is no plausible, compelling reason for SBRT (over other forms of radiation) for this enrollee. At the present time, it arguably would be furnished outside the standard of care, as SBRT for metastatic lesions is generally only indicated for enrollees with limited metastatic disease.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 5 fractions of SBRT have not been met.Therefore, we decided that the Plan does not have to pre-approve5 fractions of stereotactic body radiation therapy (SBRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of previous root canal therapy and resin-based composite provided on December 9, 2019 by an OON provider.You asked the Plan to pay for the retreatment of previous root canal therapy and resin-based composite. You say that your dentist referred you to an in-network endodontist, but they could not fit you in their schedule for months. You also say that you self-directed to an OON dentist who was able to see you right away.The Plan denied your request. The Plan says the treating provider is OON.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 OON.Therefore, we decided that the Plan does not have to pay for the retreatment of previous root canal therapy and resin-based composite provided on December 9, 2019 by an OON provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodontal follow up appointment (D4910) provided July
17, 2019.
You asked the Plan to pay for the dental services. You say that the service should be covered. The Plan denied
your request. The Plan says you had no supplemental dental benefits elected for 2019.
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 a periodontal follow up
appointment (D4910) provided July 17, 2019.