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

We decided that the Plan does not have to pay and additional amount for the comprehensive oral evaluation (D0150), prophylaxis (D1110), and the complete series x-ray (D0210) provided on April 14, 2021.
You asked the Plan to pay and additional amount for the dental services. You say that the dental office advised that they accept Medicare. You say that you did not know that the dental office was out of network and would cost more. You say that you would not have made the appointment had you known. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that out of network dentists may bill you for any amount greater than what the plan pays.
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 and the services are listed as covered, dental services performed out of network may have a higher cost share. The Evidence of Coverage clearly states that out of network dentists may bill you for any amount greater than the maximum allowable charge (MAC). Therefore, we decided that the Plan does not have to pay and additional amount for the comprehensive oral evaluation (D0150), prophylaxis (D1110), and the complete series x-ray (D0210) provided on April 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services (Q9996) provided to the enrollee on November 20, 2020.
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 Healthcare Common Procedure Coding System (HCPCS) code Q9966 (8 units) remains not supported.
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 HCPCS Q9996 is "injection of low osmolar contrast material, 200-299 mg/ml iodine concentration" We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the documentation does not support eight units billed. Omnipaque 240 - 4 injections of .5cc were given, equals 2 units should be billed. Isovue 200 - 3 injections of .5 cc were given, which equals 2 units with JW modifier.
We looked at this coder'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 pay for injection services (Q9996) provided to the enrollee on November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on March 25, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you believe this service should be covered because you are enrolled in the dental rider. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.

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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on March 9, 2020 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on March 25, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pre-approve additional transportation.
You asked the Plan to pre-approve additional trips. You say that you need these services. The Plan denied your request. The Plan says that 24 one-way trips are covered per year. The Plan also says that the benefit has been exhausted.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide a copy of the applicable trip record for this case. We asked for this document, but it was not provided to us. Without this information we cannot determine that the enrollee's routine transportation benefit has been exhausted. Therefore, the Plan has not substantiated their denial in this case. Therefore, we decided that the Plan has to pre-approve additional transportation.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on January 22, 2021.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not ordered by the enrollee's treating physician and the enrollee denies a relationship with the ordering provider.
The Plan must follow Medicare rules. Medicare rules say that diagnostic laboratory tests must be ordered by the physician who is treating the beneficiary.
We looked at the file and Medicare rules. The documentation does not show that this testing was ordered by the
enrollee's treating physician, and the Plan has attested that the enrollee denied any relationship with this
ordering provider. Based on this information, we decided that Medicare rules for coverage of genetic testing
have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided on
January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the primary care visit you had on May 10,
2021.

You asked the Plan to waive the copayment for the primary care visit. You say that you went to the doctor's
office for your annual wellness visit. You don't think that a copayment should apply just because your
prescriptions were refilled. The Plan denied your request. The Plan says you were charged this copayment
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 $20
copayment for primary care visits.

You have been asked to pay a $20 copayment for the primary care visit. Billing records show that you received
services during this visit beyond the scope of the services included in an Annual Wellness Visit. That is why a
separate office visit copayment applies. 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 primary
care visit you had on May 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on January 19, 2021, by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the rendering physician depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance company. The Plan denied your request. The Plan says prior authorization was not 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 subsequent nursing facility care provided on January 19, 2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vertiflex device (22869).

You asked the Plan to pre-approve a vertiflex device. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 service is not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and needs more research to show safety and efficacy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a vertiflex device have not been met. Specifically, this device is experimental and needs more research to show safety and efficacy. This means the item is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve a vertiflex device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee during a facility stay on February 18, 2021.

You asked the Plan to pay for this claim. You say that this equipment should be covered by the Plan. The Plan denied your request. The Plan says this claim should be submitted to the facility.

The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This equipment was used during and after a surgical procedure by the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee during a facility stay on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant (D6010), bone graft at time of implant placement (D6104), first 15 minutes of deep sedation/general anesthesia (D9222), each subsequent 15 minute increment of deep sedation/general anesthesia (D9223), and therapeutic parenteral drug (D9610) provided on January 29, 2021.
You asked the Plan to pay for the endosteal implant, bone graft, deep sedation/general anesthesia services, and therapeutic parenteral drug. You say that the office had verified your coverage and you assumed they had gotten pre-authorization for your treatment. The Plan denied your request. The Plan says these services are not covered by the Plan.
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 record shows that the office submitted a treatment plan that was signed by you acknowledging that none of these services would be covered, and you would be fully responsible for the cost of these services. Therefore, we decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant (D6010), bone graft at time of implant placement (D6104), first 15 minutes of deep sedation/general anesthesia (D9222), each subsequent 15 minute increment of deep sedation/general anesthesia (D9223), and therapeutic parenteral drug (D9610) provided on January 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the patient requires and is more appropriate for extended acute care. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (36415, 80053, 82306, 83036, 84443, 85025) rendered by the out-of-network (OON) provider on August 18, 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 (36415, 80053, 82306, 83036, 84443, 85025) rendered by the out-of-network (OON) provider on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided out of network on January 31, 2021.

You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.

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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided out of network on January 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee brace (L1851).

You asked the Plan to pre-approve a knee brace. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item 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 knee brace. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that detailed documentation is not evident regarding any objectively confirmed instability. Furthermore, there are no recent injuries or surgeries documented for the right knee. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 

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 knee brace have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee brace (L1851).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LINX procedure.

You asked the Plan to pre-approve LINX procedure. You say that the LINX system can no longer be considered experimental/investigational and is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the LINX procedure is experimental/investigational.

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 LINX procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found esophagogastroduodenoscopy (EGD) showed no evidence of advanced esophageal injury due to acid exposure. No pH study was provided to corroborate symptoms with acid reflux events. The enrollee's lower esophageal sphincter functions normally and does not require surgical augmentation. The enrollee's history of solid food dysphagia as well as radiographic evidence of dysmotility with hang-up of a barium pill at the gastroesophageal junction indicates potential contraindications to LINX.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of LINX procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the LINX procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3320) provided on March 22, 2021.
You asked the Plan to pay for the dental service. You say that this was an emergency. You say that of the list of in network providers you received, some of the phone numbers did not work. You say that other providers were no longer in network with your plan. You also say that you feel an exception should be made. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that you must visit a participating dental provider to receive dental 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 and root canal is listed as covered, dental service performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the root canal (D3320) provided on March 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97110), neuromuscular reeducation (97112), PT evaluation (97163), and therapeutic activities (97530) provided from April 28, 2021, to April 30, 2021 by an OON provider.
You asked the Plan to pay for the therapeutic exercises, neuromuscular reeducation, PT evaluation, and therapeutic activities. The Plan denied your request. The Plan says these services were rendered by a non-network provider. The Plan also says that the services were not referred by a network provider nor were they approved in advance.
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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the therapeutic exercises (97110), neuromuscular reeducation (97112), PT evaluation (97163), and therapeutic activities (97530) provided from April 28, 2021, to April 30, 2021 by an OON provider.