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

We decided that the Plan does not have to pay for the endodontic procedure (D3999) and therapeutic parenteral drug (D9610) provided on February 18, 2021.
You asked the Plan to pay for the endodontic procedure and therapeutic parenteral drug. You say that you were not aware these services were not covered. The Plan denied your request. The Plan says these services 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the endodontic procedure (D3999) and therapeutic parenteral drug (D9610) provided on February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office or other outpatient visit provided on January 5, 2021.
You asked the Plan to pay for the office or other outpatient visit (99214). You say that POS 12 is an allowable location for all temporary telephonic codes. The Plan denied your request. The Plan says the POS code is incorrect.
The Plan must follow Medicare rules. Medicare rules say that when completing the 1500 claim form, providers must enter the correct Place of Service (POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. In this case, code 99214 cannot be paid as billed due to an error with the POS code reported. Medicare billing criteria are not met.
We find that POS code 12 is incorrect. Based on this information, we decided that Medicare rules for coverage of the office or other outpatient visit (99214) have not been met. Therefore, we decided that the Plan does not have to pay for the office or other outpatient visit provided on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) provider.
You asked the Plan to pre-approve the continuation of care with an OON provider. You say that you have been seeing this OON provider for over 30 years. You say that you were approved to see this OON provider last year. The Plan denied your request. The Plan says the services in dispute are not an emergency and can safely be rendered in-network.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for 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 continuation of care with an OON provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found the available records do not support medical necessity, nor does a clinical emergency exist to warrant ongoing OON care. In-network specialty care expertise exists for the routine GI evaluation, GI management, and GI procedural follow-up of the non-acute GI conditions for the enrollee. 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 continuation of care with an OON provider have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on February 19, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 February 19, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home nursing care (S9123) provided from February 3, 2021, to February 8, 2021.
You asked the Plan to pay for home nursing care. You say that these services were medically necessary. The Plan denied your request. The Plan says these services were not billed with a valid code.
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 code S9123 is not supported in the medical record. Specifically, this code has a status
indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home nursing care have not been met. Therefore, we decided that the Plan does not have to pay for home nursing care (S9123) provided from February 3, 2021, to February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the crown (D2751) provided on February 17, 2021.
You asked the Plan to reimburse you for the dental service. You say that you thought the crown was a covered service. You also say that you cannot pay more than the $63 that you were reimbursed for the cleaning. The Plan denied your request. The Plan says crown is not listed as a covered service.
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 reimburse you for the crown (D2751) provided on February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FISH cytopathology provided on January 19, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this 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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that the enrollee is an 83-year-old female with reported hematuria. FISH cytopathology for urinary specimen was requested. The provided records did not show that other first and second-line testing methods were performed to help discover the etiology of the hematuria to justify moving to this third-line testing method. Therefore, without sufficient support made for this request, the FISH cytopathology will be considered not medically necessary based on the provided documentation. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the FISH cytopathology provided on January 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ice machine (E1399).
You asked the Plan to pre-approve an ice machine. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve an ice machine (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781) provided on March 12, 2021.
You asked the Plan to pay for the progressive lenses (V2781). You say that you need progressive lens because you have very bad eyesight. The Plan denied your request. The Plan says progressive lenses are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover progressive lenses.
We looked at the file and the Medicare rules. Medicare does not cover progressive lenses. Therefore, we
decided that the Plan does not have to pay for progressive lenses (V2781) provided on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulmonary tests provided on March 31, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the pulmonary tests. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 pulmonary tests provided on March 31, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Doxil.
You asked the Plan to pre-approve Doxil. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this is not a covered benefit because the enrollee is enrolled in a clinical trial.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve Doxil as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Doxil.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered due to a failed home assessment.
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 the wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the documentation indicates that your home does not have a path for the wheelchair to move safely around. Therefore the criteria for the power wheelchair has not been met. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Simponi Aria Solution.
You asked the Plan to pre-approve the Simponi Aria Solution. You say that reasonable medical evidence, clinical experience, and this particular clinical situation having failed multiple other therapeutic options, all support the use of the requested drug. The Plan denied your request. The Plan says that medical studies haven't proven that the requested drug is helpful for treatment of hidradenitis suppurativa.
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 the Simponi Aria Solution. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has failed the FDA TNF-alpha inhibitor adalimumab and, therefore, should be allowed to try another TNF-alpha inhibitor golimumab known to work in such patients. 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 Simponi Aria Solution have been met. Therefore, we decided that the Plan has to pre-approve Simponi Aria Solution.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a cardiologist on January 21, 2021.
You asked the Plan to waive the copayment for the cardiology visit. You say that you didn't know that there would be a copayment for this service. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that the cardiologist you saw is a Tier 2 specialist.
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 office visits with a Tier 2 specialist.
You have been asked to pay a $50 copayment for the cardiology visit. The cardiology visit falls within the office visits with a Tier 2 specialist 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 office visit you had with a cardiologist on January 21, 2021.
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 IRF care is medically necessary in order for the enrollee to get the therapy that he needs to be independent. The Plan denied your request. The Plan says the requirements for approval of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed 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 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for bacteremia and a urinary tract infection. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for biofeedback treatments provided by a chiropractor from July 31, 2020, to August 25, 2020.
You asked the Plan to pay for biofeedback provided by a chiropractor. You say that this treatment should be covered by the Plan. The Plan denied your request. The Plan says biofeedback is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for biofeedback treatments provided by a chiropractor from July 31, 2020, to August 25, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for one the cystourethroscopies provided on January 13, 2021 and January 20, 2021.
You asked the Plan to waive the copayment for a cystourethroscopy. You say that the procedure was only partially successful so why should you have to pay two copayments. The Plan denied your request. The Plan says you were charged the copayments 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 $245 copayment for outpatient Surgery.
You have been asked to pay a $245 copayment for each of the cystourethroscopies. The cystourethroscopies fall within the Outpatient Surgery 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 one of the cystourethroscopies provided on January 13, 2021 and January 20, 2021. Please note, your complaint is not a valid appeal for medical coverage. Your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for all of the chiropractic services provided on February 16, 20201.
You asked the Plan to pay for codes not related to manual manipulation. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says Medicare and the Plan only cover manual manipulation of the spine. The Plan states the claim has been reprocessed to covered manual manipulation, but all other services provided remain denied.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for all of the chiropractic services provided on February 16, 20201.
Appeal type: Inpatient Hospital
Decision: Unfavorable

You asked the Plan to pre-approve IRF care. You say that you are unhappy with the care you are currently receiving and admission to an IRF is medically necessary. The Plan denied your request. The Plan says the records show that your care is routine, and you do not need a team of providers. You can safely receive the services you need in other settings such as a skilled nursing facility, home with home health services or at home with outpatient therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.