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

We decided that the Plan does not have to pre-approve Facet Radiofrequency Ablations (CPT code(s): 64635
and 64636), for the enrollee.
You asked the Plan to pre-approve the services. You say that it is medically necessary based on spondylosis
without myelopathy or radiculopathy, lumbosacral region. The Plan denied your request. The Plan says the
Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. The enrollee had two (2)
radiofrequency ablation sessions already performed on September 18, 2020, and October 2, 2020, in the lumbar
region. Review of the documentation indicates that this request would exceed the limitation of no more than
two (2) radiofrequency ablation sessions in any rolling twelve (12) month period per region, in this case, the
lumbar region. The Plan states the enrollee would not be eligible for a repeat facet radiofrequency ablation until
September 19, 2021. The request for repeat radiofrequency ablation sessions is denied as not medically
reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve Facet
Radiofrequency Ablations (CPT code(s): 64635 and 64636), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forexercise equipment and a health club membership purchased on January 30, 2020.You asked the Plan to pay forthe health and wellness services. You say that it is a different allowance for equipment reimbursement so you should receive the full amount.The Plan denied your request. The Plan says you have exhausted your $300 wellness benefit. The Plan sent an email stating that for a limited time, your wellness allowance can also be used to purchase exercise equipment for the home. You were previously reimbursed $69 for your health club membership and $231 for exercise equipment. The full $300 allowance has already been reimbursed and you are responsible for all charges over this limit.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $300 for health and wellness services. The Plan's rules for coverage of gym benefits have not been met because the record indicates that you have exhausted the allowance for this benefit. The text of the email regarding home gym equipment indicates only that you can now use your $300 wellness allowance to purchase exercise equipment for use at home. This email does not indicate that there is a new separate benefit for gym equipment or that the allowance amount has been increased, only that the types of items/services that can be covered has beenexpanded. The record shows that the Plan has reimbursed you the full $300 for qualifying health and wellness services. Therefore, we decided that the Plan does not have to pay forexercise equipment and a health club membership purchased on January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the comprehensive periodontal evaluation provided on March 9, 2021.

You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you feel insurance should cover this service. The Plan denied your request. The Plan says that no payment can be made because the treating provider has opted out of participating in Medicare programs.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage.

The record shows that you received a comprehensive periodontal evaluation, and your EOC states the Plan covers 1 oral exam every 6 months. The Plan denied this service saying no payment can be made because provider has opted out of Medicare. The EOC does not state that services rendered by a Medicare opt out provider are not covered. The documentation also does not show that you received a second oral exam within 6 months of this March 9, 2021 date of service.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the comprehensive periodontal evaluation have been met. Therefore, we decided that the Plan has to pay for the comprehensive periodontal evaluation provided on March 9, 2021.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an infusion of hydration for the first hour (96360) and for each additional hour (96361), provided on October 26, 2020.

You asked the Plan to waive the coinsurance for an infusion of hydration. You say that the coinsurance should be waived because you were never made aware of the charge. The Plan denied your request. The Plan says the cost share was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a 20% coinsurance for an infusion of hydration. an infusion of hydration falls within the Medicare Part B prescription drugs 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 coinsurance for an infusion of hydration for the first hour (96360) and for each additional hour (96361), provided on October 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for unspecified vision items or services purchased on November 8, 2020. You asked the Plan to pay for the items/services. You say that your appeal included proof of payment, so you do not understand what else could be required. The Plan denied your request. The Plan says the information provided with this reimbursement request is incomplete. Specifically, there is no itemized list of items/services purchased. We looked at the file and the Plan's rules. The documentation shows that you made a purchase totaling $95 on November 8, 2020. The exact items purchased on this date and the provider or retailer who furnished the items/services is not specified. There is a mention of cataract surgery on the reimbursement form, and it appears that the services or items at issue are related to vision care, but it is unclear if these are routine vision services or if these services are directly relating to the cataract surgery. Documentation indicates that the Plan has made several attempts to reach out to clarify this information but was unsuccessful. Based on the information provided, we cannot determine if Plan's rules for coverage of the items/services have been met. Therefore, we decided that the Plan does not have to pay for unspecified vision items or services purchased on November 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forradiologic examination, chest, 2 views (71046) provided November 23, 2020.You asked the Plan to pay forthe diagnostic services. You say that the services provided on this date of service were rendered appropriately in response to the enrollee's medical condition. Please reprocess the previously denied claim.The Plan denied your request. The Plan says the diagnosis code billed with this service is inconsistent with the service. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 71046 is radiologic examination, chest, 2 views.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 thediagnostic services. Our reviewer says that the Medicare criteria was not met. Our physician reviewer found diagnosis code Z87.891,personal history of nicotine dependence;billed with the radiologic examination, chest, 2 views is not an appropriate diagnosis to support the service billed, therefore 71046 is not eligible for reimbursement consideration.  Per the American College of Chest Physicians and the American College of Radiology, "In patients at risk for developing lung cancer, screening for lung cancer with chest x-ray once or at regular intervals is not recommended". 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 diagnostic services have not been met.Therefore, we decided that the Plan does not have to pay forradiologic examination, chest, 2 views (71046) provided November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and the electrocardiogram (93000) rendered by the out of network (OON) provider on September 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forProlia injections provided on June 22, 2020, and December 28, 2020.You asked the Plan to waive the coinsurance forProlia injections. You say that you were told that the provider incorrectly billed for the injections.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received a Prolia injection on June 22, 2020. The total allowed amount is $1,219.27 and 20% of that is $243.85. You received a Prolia injection on December 28, 2020. The total allowed amount is $1,172.00and 20% of that is $234.40.The total amount you owe is: $478.25. You have been asked to pay the totalcoinsuranceamount of $478.25for Prolia injections. Prolia injections fall within the Medicare Part B prescription drugs 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 coinsurance forProlia injections provided on June 22, 2020, and December 28, 2020
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 you need IRF care. 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 based on the documentation provided, you do not require the intensity of services provided at an IRF. Specifically, you have not been shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can safely be met at a lower 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the coinsurance foran ultrasound of the heart provided on November 5, 2020.You asked the Plan to waive the coinsurance foran ultrasound of the heart. You say that this should be considered as part of an annual visit and there should be no coinsurance.The Plan denied your request. The Plan says that the claims were processed correctly and the enrollee isbeing charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The Plan contract does not say in clear and accurate terms how much enrollees should expect to pay for outpatient diagnostic tests and therapeutic services and supplies. The enrollee received an ultrasound of the heart on November 5, 2020. The contract with the Plan says that enrollee's either pay $0 or 20% coinsurance for ultrasounds but does not specify under what circumstances.Therefore, the Plan did not clearly specify what enrollee's can expect to pay for ultrasounds. We looked at the contract between the enrollee and the Plan. We did not see where the contract says enrollees must pay 20% coinsurance for outpatient diagnostic tests and therapeutic services and supplies. The Plan contract does not clearly say how much enrollees must pay for outpatient diagnostic tests and therapeutic services and supplies. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information.Therefore, we decided that the Plan has to waive the coinsurance foran ultrasound of the heart provided on November 5, 2020.If the Plandoes 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 doesnot happen often. If we decide to open the case again, we will send you a letter
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentsfor the physical therapy services (97110) provided onNovember 8, 2019andNovember 27, 2019.You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the copaymentshavebeen applied correctly to the services provided.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $10 copayment for physical therapy services rendered by an in-network provider. The enrollee has been asked to pay$20($10 copayment x 2days) for the physical therapy services provided. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed topay upon enrolling in the Plan.Additionally, the Plan contacted the provider's office on May 10, 2021 and confirmed that the enrollee is only responsible for the copayments applied for the services provided in this case. Therefore, we decided that the Plan does not have to waive the copaymentsfor the physical therapy services (97110) provided on November 8, 2019 and November 27, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 14, 2020.
You asked the Plan to pay for the ambulance services. 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 December 14, 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 December 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided
on February 18, 2021.
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you were not
aware that you would owe a copayment. The Plan denied your request. The Plan says the claims were
processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20
copayment for outpatient rehabilitation services.
You have been asked to pay a $20 copayment for outpatient rehabilitation services. Outpatient rehabilitation
services fall within the outpatient rehabilitation services 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 outpatient rehabilitation services provided on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0230), and a 2D
oral/facial photographic image (D0350) provided on March 9, 2021.

You asked the Plan to pay for an intraoral periapical radiographic image, and a 2D oral/facial photographic
image. You say that you did not receive the services listed in your statement. The Plan denied your request.
The Plan says the intraoral periapical radiographic image is a covered benefit, but you have exceeded the
frequency limit of one every calendar year. The 2D oral/facial photographic image 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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of an intraoral periapical radiographic image, and a 2D oral/facial photographic image have not been
met. Specifically, the record shows that you had exceeded the frequency limit for the intraoral periapical
radiographic image. Additionally, the 2D oral/facial photographic image is not a covered benefit. Therefore, we
decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0230), and a 2D
oral/facial photographic image (D0350) provided on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression garments provided on January 7, 2021.
You asked the Plan to pay for the services provided. You say that the garment is for your chronic condition. The Plan denied your request. The Plan says you purchased an item from a non-certified provider.
The Plan must follow Medicare rules. The rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and the rules. The records do not show that the provider in this case is eligible to provider services under Original Medicare. We found no exception that would require the Plan to pay for the services at issue. Therefore, we decided that the Plan does not have to pay for the compression garments provided on January 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC) and attachments for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that they do not see evidence that shows that the member has the mental and physical capability to safely operate the power wheelchair in the home.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 these services are not medically reasonable and necessary for the enrollee. The enrollee has Chronic inflammatory demyelinating polyneuropathy and GALOP syndrome (gait ataxia, late-onset polyneuropathy). The enrollee has difficulty walking. Dementia with memory loss is documented.
The enrollee is unable to complete ADLs without needing to sit down. It is documented that the enrollee is unable to operate the remote, microwave, and some other small appliances. On March 1, 2021, the enrollee ambulated 100 feet with a rollator device. The enrollee has 5/5 upper extremity strength bilaterally. It is not clearly demonstrated that the enrollee in this case can safely use a PMD. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC) and attachments for the enrollee.