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

We decided that the Plan does not have to waive the deductible for the office visit provided on August 24, 2020.
You asked the Plan to waive the deductible for the office visit. You say that you paid your $30 copayment but were billed the remaining balance. The Plan denied your request. The Plan says the deductible applied correctly.
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 your deductible is $185. This is the amount you have to pay out-of-pocket before the Plan will pay its share for your covered Medicare Part A and B services. The item or service you asked the Plan to waive the deductible for falls within the "Podiatry services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $185 deductible applies to podiatry services. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on August 24, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically
necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically
necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a Vertiflex device. Our reviewer says
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is
diagnosed with lumbar spinal stenosis with neurogenic claudication. The Vertiflex device is experimental.
More research is needed to show safety and efficacy. Open laminectomy remains the gold standard for spinal
stenosis decompression.
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 Vertiflex device have not been met. Therefore, we decided that the Plan does
not have to pre-approve a Vertiflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. You asked the Plan to pre-approve the compression stockings. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered. The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral radiographic imaging (D0220) and the core buildup procedure (D2950) provided on November 17, 2020. You asked the Plan to pay for the dental services. You say that you had a new dentist perform this procedure and you should still have benefits for these services. The Plan denied your request. The Plan says you have already had one intraoral radiographic imaging service done this year, and the Plan only covers one per year. Additionally, the core buildup procedure is not covered by Medicare or by the Plan's supplemental dental 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. The Plan provided documentation that you already received an intraoral radiographic imaging service in August of this year. This service is only covered once every calendar year. Additionally, the core buildup procedure is not listed as service that is covered by your supplemental dental benefits. Therefore, we decided that the Plan does not have to pay for the intraoral radiographic imaging (D0220) and the core buildup procedure (D2950) provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ophthalmologist visit (92004, 92014) to be provided
by an OON provider.
You asked the Plan to pre-approve an OON ophthalmologist visit. You say that your representative had a good
experience with the requested OON provider, and the in-network doctor cannot see you until June. The Plan
denied your request. The Plan says this service is available in-network and appointments are available in
March.
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
an ophthalmologist visit (92004, 92014) to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on October 21, 2020.

You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on October 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bilevel positive airway pressure (BiPAP) device with humidifier.
You asked the Plan to pre-approve these services. You say that your current machine is too large and you prefer this smaller machine. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that replacement DME is covered when it is irreparably damaged or has exceeded the reasonable lifetime period. We looked at the file and Medicare rules. The file shows that you currently have a BiPAP device and humidifier. Your current equipment is not irreparably damaged and has not exceeded the reasonable lifetime period of five years. Therefore, we decided that the Plan does not have to pre-approve a bilevel positive airway pressure (BiPAP) device with humidifier.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar laminectomy.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis. There is no recent magnetic resonance imaging (MRI) showing severe compression of the nerve roots. The criteria for the requested surgery are not met and the services are not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar laminectomy.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study and oral appliance (G0398, E0486) to be
provided by an OON provider.
You asked the Plan to pre-approve the sleep study and oral appliance. You say that the services are medically
necessary. The Plan denied your request. The Plan says there are network providers available.
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
a sleep study and oral appliance (G0398, E0486) to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (HCPCS R0070) provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the place of service was inappropriate for this procedure.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that HCPCS code R0070 is not supported in the medical record. Specifically, the enrollee was in a
skilled nursing facility setting on the date of service. R0070 is a technical component-only code and should
only be reported in the hospital setting. 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 pay for radiology
services (HCPCS R0070) provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A4500.
You asked the Plan to pre-approve the compression stockings. You say that you need them for varicose veins in your legs. Your doctor suggested them, and elastic bandages do not work for you anymore. The Plan denied your request. The Plan says this item is not covered.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A4500 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A4500.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 19, 2020. You asked the Plan to pay for the physician's services. 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 physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on October 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need to get strength and mobility with the requested therapy in order to go home. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 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. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an LSO (L0650) provided on September 28, 2020.
You asked the Plan to pay for an LSO. You say that the requested item is medically necessary. The Plan denied your request. The Plan says rules for payment have not been met because the record contains insufficient documentation of a physician examination.
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 an LSO. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation that there was an injury or surgical procedure. There is no evidence of a weakened or deformed spine as no strength evaluation or imaging is provided. The documentation provided does not credibly establish that an examination of the enrollee occurred to make the noted diagnoses. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an LSO have not been met. Therefore, we decided that the Plan does not have to pay for an LSO (L0650) provided on September 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services received by the enrollee from August 20, 2020 to September 3, 2020.
You asked the Plan to pay for the SNF services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that daily skilled services were not necessary. Our physician reviewer found the enrollee was independent for transfers and most activities of daily living. There were no reports of any medically unstable conditions. The documentation does not support that the enrollee required skilled nursing or skilled therapy services on a daily basis in the SNF setting. Therefore, the enrollee did not meet criteria for the SNF coverage.
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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services received by the enrollee from August 20, 2020 to September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says these services are either not covered by Medicare or exceed your supplemental benefit limit.
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. You received five tooth extractions, three of which the plan agreed to cover. The Plan contract states that the maximum number of tooth extractions covered in a calendar year is three, therefore the remaining two tooth extractions are not covered. In addition, the alveoloplasty and consultation are not part of your supplemental benefit.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services either exceed or are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two tooth extractions, the alveoloplasty, and the consultation.
Your complaint about the provider using out of network doctors 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 waive the copayment for an office visit provided on December 2, 2020.

You asked the Plan to waive the copayment for office visit. You say that you are not the one who requested this visit. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $40 copayment for specialist office visit. 

You have been asked to pay $40 copayment for office visit. Office 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 an office visit provided on December 2, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta, 32 mg vial.
You asked the Plan to pre-approve Zilretta. You say that the office does not provide dexamethasone or
triamcinolone injections for the enrollee's treatment. You also say that the enrollee was approved for this
injection just last year. The Plan denied your request. The Plan says Zilretta is subject to prior authorization.
The Plan says that in order for this drug to be covered, the enrollee must have had adequate trial of
dexamethasone injection and triamcinolone injection with an inadequate response or intolerance.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Zilretta. Our reviewer says that Zilretta
is not medically necessary. Our physician reviewer found there is no documentation which shows that the
enrollee has tried and failed the required drugs. The reviewer found that there is no documentation provided
indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the
enrollee. Therefore, the reviewer found that Zilretta 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to
pre-approve Zilretta, 32 mg vial.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nystatin powder.
You asked the Plan to pre-approve Nystatin powder. You say that the enrollee has tried and failed Nystatin
cream/ointment. You also say that the enrollee requires the powder to help resolve. The Plan denied your
request. The Plan says the requested drug is considered self-administered. The Plan says self-administered
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not
covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nystatin powder.
Benefits for Nystatin powder may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 7, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 7, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 7, 2020.