Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 19, 2020 by a non-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-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 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 laboratory services provided on November 19, 2020 by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 24, 2020 by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating 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 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 office visit provided on August 24, 2020 by a
non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation and management (E/M) services (99441) provided on January 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the telephone E/M visit. You say that please see the attached Medicare fee sheet showing that this code is billable and allowable. Please reprocess accordingly. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 telephone evaluation and management (E/M) services (99441) provided on January 7, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110) and periodic oral evaluation (D0120) provided on April 8, 2021.
You asked the Plan to pay for the dental services. You say that you were not informed that this provider was not part of the Plan's network, so you feel you should not be responsible for this bill. The Plan denied your request. The Plan says out-of-network dental care is not covered. The Plan also states that there is no record of you contacting the Plan prior to the date of service to verify benefits and provider eligibility.
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, items and services received out-of-
network are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110) and periodic oral evaluation (D0120) provided on April 8, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine, non-emergency transportation trips.
You asked the Plan to provide coverage for additional routine, non-emergency transportation trips. The Plan denied your request. The Plan says your Plan does not cover more than 50 one-way trips per Plan year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 50 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine, non-emergency transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam provided on January 18, 2021.
You asked the Plan to pay for the eye exam. The Plan denied your request. The Plan says routine eye exams are not covered by out-of-network providers.
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the eye exam was provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for an eye exam provided on
January 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve OON services. You say that the enrollee is at greater risk for falls. The Plan denied your request. The Plan says the service is available by a provider in the enrollee's 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 physical therapy services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical and occupational therapy to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.

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-approve physical and occupational therapy to be rendered by the out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81286, 81404, 81407, 81408, 81479) provided December 4, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for patients with suspected or documented cardiovascular disease. 

We looked at the file and Medicare rules. Cardiovascular risk assessment testing is not covered. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81286, 81404, 81407, 81408, 81479) provided December 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve partial dentures (D5820, D5821).

You asked the Plan to pre-approve partial dentures. You say that you did not receive the notice of changes stating that dentures would not be covered in 2021. The Plan denied your request. The Plan says dentures are not covered under your 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. Therefore, we decided that the Plan does not have to pre-approve partial dentures (D5820, D5821).

Your complaint about not receiving the Annual Notice of Changes for 2021 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D2740, D2950).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services (D2740, D2950).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Privigen.

You asked the Plan to pre-approve Privigen. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Privigen. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a past medical history of interstitial lung disease who has undergone bilateral lung transplantation. Based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that the requested use of Privigen is Food and Drug Administration-approved for the enrollee's diagnosis. Based on the medical records provided and the Medicare-approved major drug compendia and the CMS-approved medical journals there is no documentation that Privigen use is supported for lung transplantation status (rejection prophylaxis). Therefore, the enrollee does not meet criteria for the requested drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Privigen have not been met. Therefore, we decided that the Plan does not have to pre-approve Privigen.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic connection E2311 expandable controller E2377 and expandable controller harness E2313 and footplate extension K0108 seat elevator (E2300) and bag hooks (K0108).

You asked the Plan to pre-approve the upgraded electronics, seat elevator and bag hooks. You say that you believe the denied services should be covered because of your medical condition. Your arms became numb constantly cause you to lose function temporarily and is the reason why you need the additional features. The Plan denied your request. The Plan says the seat elevator and bag hooks do not serve a primary medical purpose and is not covered. The upgraded electronics are not medically necessary to control the three approved power options through the joystick. The footplate extension exceeds the enrollee's need.

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 upgraded electronics, seat elevator and bag hooks. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices or non-proportional input devices. The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display, other electronic devices or an attendant control. The enrollee's strength and function in the upper extremities with the ability to catheterize herself supports that the patient can control any power options through their own individual switches. 

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 upgraded electronics, seat elevator and bag hooks have not been met. Therefore, we decided that the Plan does not have to pre-approve electronic connection E2311 expandable controller E2377 and expandable controller harness E2313 and footplate extension K0108 seat elevator (E2300) and bag hooks (K0108).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325).

You asked the Plan to pre-approve Synvisc-One (J7325). You say that you want to treat the enrollee with this
drug. The Plan denied your request. The Plan says the enrollee has not first tried and failed Orthovisc and
Monovisc.

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 Synvisc-One (J7325). Our reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer found based on the medical records provided the patient has not tried and failed the required drug(s). Based on the medical records provided there is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the patient. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift chair (A9270).

You asked the Plan to pre-approve a seat lift chair. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says the requested item is not a Medicare benefit.

The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to a seat lift mechanism. 

Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide
coverage only for items that Medicare covers. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair (A9270).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve for guided tissue regeneration, resorbable barrier, per site, tooth #14 (D4266).

You asked the Plan to pre-approve for the dental service. You say that you are appealing the denial of the dental services. The Plan denied your request. The Plan says this service is not covered under the plan 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 health plan contract specifically says that any service not listed under the list of covered dental procedures is not covered by the Plan. 

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-approve for guided tissue regeneration, resorbable barrier, per site, tooth #14 (D4266).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiotherapy.

You asked the Plan to pre-approve proton beam radiotherapy. You say that this request is medically necessary. The Plan denied your request. The Plan says the enrollee does not a covered indication for the requested proton beam radiotherapy.

The Plan follows Medicare rules. Medicare rules say that the enrollee must have a covered indication for proton beam therapy as listed 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 proton beam radiotherapy. Our reviewer says that the requested procedure is not medically reasonable and necessary for the enrollee's condition.

Our physician reviewer found that based upon the provided records it is not plausible that proton therapy would provide a clinically meaningful benefit over a well-designed IMRT plan. While not experimental, its potential benefit over non-proton based radiation is an investigational question. Skin cancers are not included as Group 1 or 2 conditions in the LCD. Therefore, the enrollee does not have a covered indication for the requested procedure. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam radiotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiotherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an annual digital rectal exam provided by a participating provider on November 2, 2020.

You asked the Plan to waive the copayment for an annual digital rectal exam. You say that this should be covered. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $15 copayment for prostate cancer screening exams. 

You have been asked to pay a $15 copayment for an annual digital rectal exam. The correct copayment has been applied to the services that were provided. An annual digital rectal exam falls within the prostate cancer screening exams 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 annual digital rectal exam provided by a participating provider on November 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided March 23, 2021.

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says required documentation related to the delivery is missing.
The Plan must follow Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria coverage listed 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 pay for the knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically necessary and reasonable. Our physician reviewer found that the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, there is insufficient credible objective documentation of joint laxity. 

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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided March 23, 2021.