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

We decided that the Plan does not have to pay for the dental services (D7140, D0484, D4263) received April 9,
2020, and September 8, 2020, from the opt-out provider.
You asked the Plan to pay for the dental services. You say that you were not told by anyone that you could not
see this provider. The Plan denied your request. The Plan says the provider in this case was opted out of
Medicare on these dates of 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 requested items or services are not
among those covered under this benefit. The provider in this case was opted out of Original Medicare on the
dates of service in dispute. Therefore, we decided that the Plan does not have to pay for the dental services
(D7140, D0484, D4263) received April 9, 2020, and September 8, 2020, from the opt-out provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on April 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. 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 the laboratory work provided on April 21, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist
device (L8702).
You asked the Plan to pre-approve this item. You say that this device is medically necessary. The Plan denied
your request. The Plan says this device is not medically necessary and exceeds your needs.
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 this item. Our reviewer says that the
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found
that according to Medicare an item is medically reasonable and necessary if it is safe and effective and not
mainly for the convenience of the patient or the physician. In order to be considered medically necessary an
item cannot be investigational or experimental and must be ordered by qualified personnel and be appropriate
to the patient's medical needs and condition. Additionally, there must be a duration and frequency that is
considered appropriate and the durable medical equipment should not be considered to have deluxe features. In
this case, the requested durable medical equipment appears to be deluxe in function as the brace appears to act
as a robotic arm to restore function instead of range of motion. The requested device is not 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 this item have not been met. Therefore, we decided that the Plan does not have
to pre-approve a powered upper extremity range of motion assist device (L8702).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the mental health services provided from April 15, 2020 to May 4, 2020.
You asked the Plan to pay for the mental health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says a Licensed Marriage & Family Therapist is ineligible to enroll in Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. The services you received in this case were provided by a Licensed Marriage & Family Therapist (LMFT). This provider type is not eligible to enroll in Medicare. No provider shall receive payment for services furnished to a Medicare beneficiary unless the provider is enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the mental health services provided from April 15, 2020 to May 4, 2020.
Your complaint about the Plan providing you the incorrect 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (88350, 88346) rendered by an out of network (OON) provider on October 14, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, 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 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 the laboratory services (88350, 88346) rendered by an out of network (OON) provider on October 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met at an alternate level of care, such as skilled nursing or home health.

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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for shock, hypotension, and gastrointestinal bleeding as was discharged home on 4/24/21. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says research studies have found a lack of evidence that the requested device would improve 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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has heart failure with an ejection fraction of 15% during a hospital exacerbation and 40% at baseline. The enrollee has been hospitalized in the past year. The record does not indicate a NYHA class III classification. The enrollee becomes fatigued with exertional activity not ordinary activity. The elements of the coverage criteria are not satisfied. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an annual wellness exam provided on
December 2, 2020.
You asked the Plan to waive the deductible for an annual wellness exam. You say that you disagree with the
charges because this was your annual wellness exam, and you should not owe a copayment. 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. Your
contract with the Plan says that there is a $500 deductible for out-of-network annual wellness visits.
The record shows that you had an annual wellness exam with an out-of-network provider on December 2,
2020. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The record
shows that you had paid $0 toward the $500 deductible prior to receiving the services. Therefore, you are
responsible to pay the total allowed amount of $116.44.
The item or service you asked the Plan to waive the deductible for falls within the benefit category annual
wellness visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500
deductible for out-of-network annual wellness visits. This cost sharing is a contractual obligation that had not
been met at the time an annual wellness exam was received on December 2, 2020. Therefore, we decided that
the Plan does not have to waive the deductible for an annual wellness exam provided on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction services described by current procedural terminology (CPT) code 92015 provided on January 21, 2021.
You asked the Plan to pay for CPT code 92015. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider is not part of the Plan's in-Plan vision care provider network.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by an in-Plan vision care provider. We looked at the file and the Plan's rules. The file shows that the provider you received the routine vision services from is not an in-Plan vision care provider. Based on this information, we decided that the Plan's rules for coverage of CPT code 92015 have not been met. Therefore, we decided that the Plan does not have to pay for the refraction services described by current procedural terminology (CPT) code 92015 provided on January 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of inpatient care provided from April 25, 2020, through April 29, 2020.
You asked the Plan to pay for continuation of inpatient care provided from April 25, 2020, through April 29, 2020. The Plan denied your request. The Plan says the care rendered, comfort care, could have been provided at a lower level.
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 pay for continuation of inpatient care provided from April 25, 2020, through April 29, 2020. Our reviewer says that continuation of inpatient care provided from April 25, 2020, through April 29, 2020 is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was a then 91-year-old female nursing home resident with a history of Myasthenia gravis, atrial flutter, CAD, CHF, HTN, DVT, anemia and cervical and lumbar DDD who presented to the ER on April 9, 2020 with fever. Covid19 and flu swabs were obtained; CXR demonstrated a right middle lobe infiltrate. She was treated with IV fluids, supplemental oxygen and IV antibiotics (Levaquin/Cefepime) and admitted. She had a Stage III sacral decubitus ulcer and wound care was consulted. Her H was 20. She was evaluated by Nephrology as she developed anasarca. The enrollee continued with fever and IV vancomycin was added to her medical regimen. On April 25, 2020 a family meeting was held to discuss hospice care. The review indicates that for the period of April 25, 2020, through April 29, 2020 the enrollee was stable and was waiting for placement with hospice or to a lower level. The care rendered, comfort care, could have been provided at a lower level. The review has determined that the continuation of the inpatient admission provided from April 25, 2020, through April 29, 2020 was 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 continuation of inpatient care provided from April 25, 2020, through April 29, 2020 have not been met. Therefore, we decided that the Plan does not have to pay for continuation of inpatient care provided from April 25, 2020, through April 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on August 18, 2020.
You asked the Plan to pay for the physical therapy. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the physical therapy. 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 physical therapy provided on August 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the tansperineal placement of
biodegradable material and radiation therapy provided from May 20, 2020, to July 20, 2020.
You asked the Plan to waive the copayments for the tansperineal placement of biodegradable material and
radiation therapy. You say that you were never informed of the charges prior to receiving them. 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 $150
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. Your
contract with the Plan also clearly says that you must pay a $60 copayment for radiation therapy.
You received the tansperineal placement of biodegradable material at an outpatient hospital facility on May 20,
2020. The tansperineal placement of biodegradable material is considered an outpatient surgical procedure.
Therefore, you are responsible to pay the $150 copayment.
You received radiation therapy from May 20, 2020, to July 20, 2020, for a total of 33 visits. Therefore, you are
responsible to pay a $60 copayment per each radiation therapy visit. The total amount you owe is: $60
(copayment) x 33 (radiation therapy visits) = $1,980.
The total amount you owe is: $150 + $1,980 = $2,130.
You have been asked to pay the total copayment amount of $2,130 for the tansperineal placement of
biodegradable material and radiation therapy. The tansperineal placement of biodegradable material falls within
the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory
surgical centers benefit category. Radiation therapy falls 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 copayments for the
tansperineal placement of biodegradable material and radiation therapy provided from May 20, 2020, to July
20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flex-Walk system (L5981) and a multi-axial rotation unit (L5986).
You asked the Plan to pre-approve a Flex-Walk system and a multi-axial rotation unit. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested items are not medically reasonable and necessary in this case.
The Plan follows Medicare rules. Medicare rules say that a determination of the medical necessity for certain components/additions to the prosthesis is based on the beneficiary's potential functional abilities. 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 a Flex-Walk system and a multi-axial rotation unit. Our reviewer says that the requested items are not medically reasonable and necessary. Our physician reviewer found that the enrollee has a history of absence of left lower leg and complained of ill-fitting prosthesis due to weight gain. The records did not indication that the enrollee is currently ready to use a K3 level device with the requested features to justify this request. Based on the provided documentation, the
enrollee does not meet Medicare criteria for the L5981 Flex-Walk system or for the L5986 multi-axial rotation unit. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Flex-Walk system and a multi-axial rotation unit have not been met. Therefore, we decided that the Plan does not have to pre-approve a Flex-Walk system (L5981) and a multi-axial rotation unit (L5986).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nerve blocks (CPT 64447 and CPT 64450) for the enrollee.
You asked the Plan to pre-approve the blocks. You say that this is medically necessary. The Plan denied your request. The Plan says there are multiple potential pain generators.
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 blocks. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this an experimental and investigational procedure for this problem. Therefore, the request is considered 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 blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve nerve blocks (CPT 64447 and CPT 64450) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for prostate cancer screening provided on November 10, 2020.
You asked the Plan to pay for prostate cancer screening (G0103). You say that your doctor requested this exam. The Plan denied your request. The Plan says it has not been 12 months since your last exam.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The Plan covers one exam every 12 months. You had an exam on May 8, 2020. Based on this information, we decided that Medicare rules for coverage of prostate cancer screening (G0103) have not been met. Therefore, we decided that the Plan does not have to pay for prostate cancer screening provided on November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and the intraoral - periapical each additional radiographic image (D0230) received January 27, 2021.
You asked the Plan to pay for the intraoral radiographic images (D0220, D0230). You say that the Plan should pay for the requested services. The Plan denied your request. The Plan says the requested services are not covered under your supplemental 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 intraoral - periapical first radiographic image (D0220) and the intraoral - periapical each additional radiographic image (D0230) received January 27, 2021.