Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not haveto pay for shoulder elbow wrist hand orthosis (L3960) provided on September 11, 2019.You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that this orthosis is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says the record does not include any evidence of an established relationship between the member and ordering physician.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided on September 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the prophylaxis (D1110), and the bitewing x-rays (D0274) provided on November 14, 2019.
You asked the Plan to pay for the dental services. You say that the services you received are supposed to be covered up to $2,000 per year according to the booklet that you received. You say that you are on social security. You say that you never had issues until you signed up with this Plan. You also say that when you called the Plan, you were advised that routine services are not covered. The Plan denied your request. The Plan says the oral exam, cleaning, and x-rays are not listed as covered services.
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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the prophylaxis (D1110), and the bitewing x-rays (D0274) provided on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visits provided on September 17, 2019 and September 24, 2019.You asked the Plan to waive the copayment forthe office visits. You say that you should not have to back. You say that the doctor shouldbe responsible for all costs.The Plan denied your request. The Plan says the copayment applied 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 $50 copayment for provider and professional services at an in-network specialist's office. You have been asked to pay a $50 copayment for each office visit. The total amount you owe is $100 ($50/visit x 2 visits = $100). The office visits fall 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 forthe office visits provided on September 17, 2019 and September 24, 2019.Your complaint about poor serviceis 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: Favorable

We decided that the Plan has to pre-approve radiofrequency neurolysis.
You asked the Plan to pre-approve the requested services. You say that the injections help you feel better. The Plan denied your request. The Plan says that you have not had 2 successful medial branch blocks.
The Plan follows Medicare rules. Medicare rules say that radiofrequency neurotomy is 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 services. Our physician reviewer found that you have chronic low back pain. You had 90% relief from both diagnostic medial branch blocks (MBBs). The result of the second MBB is clearly documented in the progress notes. You report that both blocks have helped. Therefore, the request for RFA 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 requested services have been met. Therefore, we decided that the Plan has to pre-approve radiofrequency neurolysis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 6, 2019 by an out of network periodontist.
You asked the Plan to pay for the dental service. You say that there are no local dentists that accept your plan. You say that you should be reimbursed for the service as there are no periodontists in the area. You also say that you are disabled and unable to travel long distances. The Plan denied your request. The Plan says the prophylaxis can be performed by a general dentist. The Plan says there are 212 in network general dentists within a 15-mile radius of your home zip code.
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, dental services received out of network are not covered. Additionally, dental services that you receive from a specialist are not covered. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 6, 2019 by an out of network periodontist.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an Electroencephalogram (EEG) extended monitoring (95813) and Needle electromyography (95861) provided May 22, 2019.
You asked the Plan to pay for the Electroencephalogram and Needle electromyography. You say that services were medically necessary. The Plan denied your request. The Plan says records do not support the services at issue.
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 CPT codes 95813 and 95861 are not supported in the medical record. Specifically, the medical records provided do not document the services at issue being performed. Based on this information, we decided that Medicare rules for coverage of the Electroencephalogram and Needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for an Electroencephalogram (EEG) extended monitoring (95813) and Needle electromyography (95861) provided May 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on September 27, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you should not have to pay for the follow up CT scan. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $225 copayment for each in-network Medicare-covered advanced imaging service (not including x-rays). You have been asked to pay a $225 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the CT scan provided on September 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the member needs hospital level care with close medical management. The Plan denied your request. The Plan says the member's condition has improved and they may safely receive care in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the member's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not appear to be able to tolerate or require Physical or Occupational Therapy on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retractable cane.
You asked the Plan to pre-approve a retractable cane. You say that you lost your cane when shopping and now you want a retractable cane to fit into your purse. The Plan denied your request. The Plan says a replacement cane, of the same type, is approved.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. Medicare provides replacement of identical or nearly identical items. The file shows you had a cane, adjustable or fixed, with tip provided in 2019. The Plan has agreed to replace this cane with an identical cane. The network provider does not carry retractable canes. Therefore, we decided that the Plan does not have to pre-approve a retractable cane.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide power wheelchair expandable control system, or power seat elevation feature.
You asked the Plan to provide power wheelchair expandable control system and power seat elevation feature. You say that the enrollee qualifies for the power tilt and recline, and expandable control system. The Plan denied your request. The Plan says a seat elevation system does not serve a medical purpose and cannot be covered, and there is no medical need to control power options through the joystick. The Plan follows Medicare rules. Medicare rules state that options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. The file shows that the enrollee has upper extremity strength and mobility to operate the switches that come with the power options. This means that Medicare rules for coverage of an expandable control system have not been met. Medicare does not cover power seat elevation features. Therefore, we decided that the Plan does not have to provide power wheelchair expandable control system, and power seat elevation feature.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the prophylaxis (D1110), the bitewing x-rays (D0274), and the panoramic x-ray (D0330) provided on September 9, 2019 by an out of network provider.
You asked the Plan to pay for the dental services. You say that you called customer service during the first week of September 2019 to inquire about in network providers in your area. You say that the plan representative advised Argyle Jax Dental was in network. You also say that you verified the information with the plan representative and made an appointment. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says that dental services received out of network are not covered.
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, dental services are not covered when you receive them out of network. The record shows that your last call to customer service was on July 31, 2019 and was not related to your dental benefits. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the prophylaxis (D1110), the bitewing x-rays (D0274), and the panoramic x-ray (D0330) provided on September 9, 2019 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from September 14, 2019 to September 18, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are handicapped, on a fixed income, and in poor health and this bill is a heavy burden. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $300 copayment per day for days 1-5 for each Medicare-covered hospital stay. You have been asked to pay a $300 copayment for each day of the inpatient hospital stay. ($300 x 4 days = $1,200). The inpatient hospital stay falls within the "Inpatient hospital care" 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 inpatient hospital stay provided from September 14, 2019 to September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-area oncology services for the enrollee.
You asked the Plan to pre-approve the out-of-area services. The Plan denied your request. The Plan says there is no evidence the enrollee is unable to return to the service area.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care. 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 out-of-area services. Our physician reviewer found that the enrollee was diagnosed with melanoma in December, while in her service area. After receiving the diagnosis, the enrollee traveled to Florida, at which time it was determined that an additional excision was medically necessary to assure complete removal of the lesion. The additional excision was performed and the lesion appears to have been fully removed. While ongoing evaluation and treatment for the melanoma itself is medically necessary, this care was foreseeable when the diagnosis was made in December. The enrollee does not currently require emergency treatment and she can safely return to her service area for ongoing care of her condition. 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 out-of-area services have not been met. Therefore, we decided that the Plan does not have to pre-approve out-of-area oncology services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to pre-approve 3 PT visits. We decided that the Plan does not have to pre-approve more than 3 PT visits.
You asked the Plan to pre-approve PT visits. You say that you had PT at this facility and you need more. The Plan says that the PT services are not medically necessary.
We decided that the Plan has to pre-approve 3 PT visits. The documentation supports 3 visits to be medically necessary. Three visits will provide adequate time to safely educate and transition the enrollee to a home exercise program for strengthening and range of motion of the left upper extremity. More than 3 visits are not reasonable and necessary.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation.
You asked the Plan to provide coverage for additional routine transportation. You say that additional routine transportation is medically necessary. The Plan denied your request. The Plan says once this benefit is exhausted it cannot be extended.
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits, they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the audiologic function tests provided on September 18, 2019.
You asked the Plan to waive the copayment for the audiologic function tests. You say that this was routine. You say that there should be no copayment. The Plan denied your request. The Plan says the copayment applied 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 $50 copayment for each Medicare-covered visit for hearing services. You have been asked to pay a $50 copayment for the audiologic function tests. The audiologic function tests falls within the "Hearing services" benefit category. The records show that these were diagnostic tests. 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 audiologic function tests provided on September 18, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried Reclast.
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 Prolia. Our reviewer says that the criteria for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial of an oral bisphosphonate drug (e.g., alendronate, ibandronate, risedronate) and zoledronic acid (generic Reclast) before they will approve the requested drug. While the enrollee has tried and failed treatment with an oral bisphosphonate (Fosamax) for two years, she has not tried zoledronic acid. The documentation is insufficient to demonstrate that zoledronic acid would likely be less effective or have adverse effects for the enrollee in this case. There is insufficient data from clinical trials to demonstrate that Prolia (Denosumab) would be more effective than zoledronic acid in a patient who has failed treatment with an oral bisphosphonate. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular reeducation (97112) services billed on October 14, 2019, October 15, 2019 and October 17, 2019.
You asked the Plan to pay for the neuromuscular reeducation services. The Plan denied your request. The Plan says the documentation does not support the number of units billed for neuromuscular reeducation (97112).
The Plan must follow Medicare rules. Medicare rules say that for timed codes, the appropriate number of units of service associated with each is required. We looked at the file and Medicare rules. In this instance, the documentation does not support the number of neuromuscular reeducation (97112) units billed for the dates of service at issue. Based on this information, we decided that Medicare rules for coverage of neuromuscular reeducation (97112) have not been met. Therefore, we decided that the Plan does not have to pay for neuromuscular reeducation (97112) services billed on October 14, 2019, October 15, 2019 and October 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SPECT test provided on May 20, 2019.
You asked the Plan to waive the copayment for the SPECT test. You say that the test was not completed and you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $275 copayment for each advanced imaging service (e.g., MRI, CT and PET scan, nuclear medicine, and stress tests). You have been asked to pay a $275 copayment for the SPECT test. The SPECT test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows the SPECT test was completed.
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 SPECT test provided on May 20, 2019.