Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve office visits. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated within the Plan 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 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 the medical services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve level 3 accessories for the enrollee's prosthesis.
You asked the Plan to pre-approve the requested items. You say that the enrollee is active and needs the prosthesis to maintain his quality of life. The Plan denied your request. The Plan says there is no information to support the enrollee is a K3 ambulator.
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested items. Our physician reviewer found that the enrollee with peripheral artery disease is post left above-knee amputation. He is stable on medications for pain control and the residual limb shows no signs of infection. The records do not suggest the level 3 items will markedly enhance functioning of the prosthesis or mobility related activities of daily living performance. These are convenience items and 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 the requested items have not been met. Therefore, we decided that the Plan does not have to pre-approve level 3 accessories for the enrollee's prosthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea crown (D2740) for tooth # 18.You asked the Plan to pre-approvethe dental service. You say that you feel the crown should be covered.The Plan denied your request. The Plan says crowns are 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 requested crown is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea crown (D2740) for tooth # 18.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on November 22, 2019.You asked the Plan to pay for the drug test. 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 drug test. 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 a drug test provided on November 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean Optune Lua device for the enrollee.You asked the Plan to pre-approvean Optune Lua device. You say that this treatment has been approved by the United States Food and Drug Administration through the HDE pathway for treatment of malignant pleural mesothelioma.The Plan denied your request. The Plan says that this is statutorily not covered by CMS for this enrollee's clinical diagnosis.The Plan must follow Medicare rules. Medicare rules say that the use of tumor treatment field therapy for any indications other than newly diagnosed Glioblastoma Multiformewill be denied as not reasonable and necessary. We looked at the file and Medicare rules. The file indicates that the Optune Lua is not being requested for the treatment of newly diagnosed Glioblastoma Multiforme. Based on this information, we decided that Medicare rules for coverage of an Optune Lua device have not been met.Therefore, we decided that the Plan does not have to pre-approvean Optune Lua device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea mandibular partial denture (D5226) and a maxillary partial denture (D5225).You asked the Plan to pre-approvethe mandibular and maxillary partial denture. The Plan denied your request. The Plan says these services are not covered benefits.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 pre-approvea mandibular partial denture (D5226) and a maxillary partial denture (D5225).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that you need a replacement power wheelchair with a power seat elevation feature.The Plan denied your request. The Plan says power seat elevation features are not covered by Medicare or the Plan.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.Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 2, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that the visit should be considered a primary care visit. 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 $45 copayment for each specialist visit. You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on December 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the eyeglasses purchased on December 5, 2019 from an out-of-network provider.You asked the Plan to reimburse for the eyeglasses. You say that you are requesting reimbursement of services rendered.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). You elected to utilize a non-contract provider and care is available in the plan network. Your EOC states you can receive care from in-network and out-of-network providers however, you will typically pay less if you use an in-network provider. Your out-of-network (POS) deductible is $1,500 was not met at the time we received your claim. 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 reimburse for the eyeglasses purchased on December 5, 2019 from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure for the enrollee.You asked the Plan to pre-approve the supplement. You say that the enrollee has poor appetite.The Plan denied your request. The Plan saysthe enrollee does not have a feeding tube, therefore this is not covered under Medicare guidelines.The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.The items you asked the Plan to pre-approve are nutritional supplements.Therefore, we decided that the Plan does not have to pre-approve Ensure for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve lower back surgery. You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says that the MRI from August 2019 does not show significant pinching of the nerves in the spine. 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 pre-approve the surgery. Our reviewer says that the requested lower back surgery is considered medically reasonable and necessary in this case. Our physician reviewer found you present with progressively worsening low back pain radiating into the right lower extremity to the foot. Significant functional limitations are noted in activities of daily living. Signs/symptoms have been consistent with neurogenic claudication. Clinical exam findings have documented motor deficits and reflex changes consistent with imaging evidence of moderate to severe L3/4 and L4/5 spinal stenosis with nerve root compromise. He has failed to achieve adequate symptom relief with reasonable and/or comprehensive
conservative treatment. Under consideration is a request for L3/4 and L4/5 decompression surgery. Current evidence based medical literature supports the use of lumbar decompression for patients with degenerative lumbar spinal stenosis with neurogenic claudication. You present with significantly debilitating symptoms of lumbar spinal stenosis with neurogenic claudication. There are clinical and imaging findings of moderate to severe spinal stenosis. You have failed conservative treatment. Therefore, this request for lumbar spine surgery is medically reasonable and 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 surgery have been met. Therefore, we decided that the Plan has to preapprove lower back surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received from an out-of-network provider from November 8, 2019, to December 3, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no referral for these services.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for the services you received from an out-of-network provider from November 8, 2019, to December 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) sensors.
You asked the Plan to pre-approve CGM sensors. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. Review of the file shows that you are requesting CGM sensors for a non-therapeutic CGM. CGMs are only covered when being used for diabetes treatment decisions in place of glucose monitors. Since non-therapeutic CGMs are not covered, any related supplies are also not covered. Based on this information, we decided that Medicare rules for coverage of CGM sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) sensors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetumor treatment field therapy (TTFT) (E0766).You asked the Plan to pre-approve tumor treatment field therapy. You say that given the aggressive nature and extremely limited treatment options, you recommend coverage for Optune, as it is the best FDA approved option at this time for treating her recurrent glioblastoma.The Plan denied your request. The Plan says that the enrollee was diagnosed with GBM in 2018.TTFT for recurrent GBMis not reasonable and necessary.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. Based on this information, we decided that Medicare rules for coverage of tumor treatment field therapy have not been met.Therefore, we decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT) (E0766).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe removal of spinal lamina (63047-AS) provided on October 17, 2019.You asked the Plan to pay forthe removal of spinal lamina. You say that you would like reconsideration because the Plan will not allow this provider type to be in network.The Plan denied your request. The Plan says certified Surgical Assistant are not recognized for payment per the Center for Medicare/Medicaid Services (CMS) guidelines.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 forthe removal of spinal lamina (63047-AS) provided on October 17, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery provided on October 15, 2019.
You asked the Plan to waive the copayment for the outpatient surgery. You say that you feel you 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 you received outpatient cataract surgery on October 15, 2019. The Plan states the correct copayment has applied per your 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). Your contract with the Plan clearly says that you must pay a $250 copayment for Outpatient surgery. We looked at the file, the Plan's contract and Medicare rules. The file shows you received outpatient cataract surgery on October 15, 2019. You have been asked to pay a $250 copayment for the outpatient surgery. The outpatient surgery falls within the Outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgery provided on October 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelabs, x-rays, and diagnostic testing to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe requested services. The Plandenied your request. The Plan says the enrollee receives care from 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approvelabs, x-rays, and diagnostic testing to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea new external ambulatory infusion pump and supplies.You asked the Plan to pre-approvethe services. You say that this is medically necessary.The Plan denied your request. The Plan says your current device is still under warranty, and it has not been five years since the purchase of this device.The Plan must follow Medicare rules. Medicare rules say that durable medical equipment replacements cannot be covered before five years of having the device. The file shows that you already have same device, and received it less than five years ago. 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-approvea new external ambulatory infusion pump and supplies
Appeal type: SNF
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b).The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe debridement services coded 11046 provided on November 11, 2019.You asked the Plan to pay forthe debridement services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed incorrectly.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 11046 is debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure).We find that CPT code 11046 is not supported in the medical record. Specifically, code 11046 is an add-on code. An add-on code is only eligible for payment if it reported with an appropriate primary procedure performed by the same provider. Review of the file shows that this code was not billed with an appropriate primary procedure. Based on this information, we decided that Medicare rules for coverage of the debridement services have not been met.Therefore, we decided that the Plan does nothave to pay forthe debridement services coded 11046 provided on November 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), comprehensive oral evaluation - new or established patient (D0150) and bitewings - four radiographic images (D0274) provided on December 11, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says they reviewed your contact history and it confirms that you never called the provider to verify benefits
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. The claim for services provided on December 11, 2019, were processed correctly at the out-of-network level of benefits for a Comprehensive Oral Evaluation which is a 100% benefit up to the Maximum Allowable Fee (MAF) per your 2019 EOC. An out-of-network provider is not bound by a contract and can therefore charge for any amount that is over the MAF. Please note that the Plan have spoken with the provider and they advised that the denied service of the additional Periapical X-ray has been written off, and you are not being billed for the service. They have sent the Plan a copy of your account showing you have a zero balance. Therefore, we decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), comprehensive oral evaluation - new or established patient (D0150) and bitewings - four radiographic images (D0274) provided on December 11, 2019 by an out-of-network provider.