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

We decided that the Plan does not have to pre-approve enteral formula and supplies.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no appropriate clinical documentation or physician's order.

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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there are no medical records detailing your condition. There is no documentation of the level of
dysphagia or feeding difficulty with enough detail to provide coverage.

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 pre-approve enteral formula and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 4, 2021 by an out of network provider.

You asked the Plan to pay for subsequent nursing facility care (99309). You say that the treatment was medically necessary. The Plan denied your request. The Plan says you did not request 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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on January 4, 2021 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation and setup of x-ray equipment provided on October 15, 2020.
You asked the Plan to pay for transportation of portable x-ray equipment (R0070) and set-up portable x-ray equipment (Q0092). You say that the Plan should pay this claim The Plan denied your request. The Plan says in this place of service the claim is not separately reimbursable.
The Plan must follow Medicare rules. Medicare rules say that that the technical component of radiology services in a SNF, during a covered stay, are not separately payable. We find that the transportation and set up costs are subject to consolidated billing. Based on this information, we decided that Medicare rules for coverage of transportation of portable x-ray equipment (R0070) and set-up portable x-ray equipment (Q0092) have not been met. Therefore, we decided that the Plan does not have to pay for transportation and setup of x-ray equipment provided on October 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression garments identified with code E1399.
You asked the Plan to pre-approve the compression garments. You say that you cannot afford to keep purchasing the compression garments since you will be dealing with lymphedema for the rest of your life. The Plan denied your request. The Plan says the requested compression garments are not a covered benefit.
The Plan must follow Medicare rules. The rules say that gradient pressure garments may be covered when used as dressings following burn injuries. In this case, the compression stockings described by code E1399 are noncovered because they do not appear to meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression garments identified with code E1399.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on February 9, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that you believe this claim was not paid but should be because the ambulance services were medically necessary. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that it has paid this claim minus your applicable copayment.
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 $265 copayment for ambulance services. You have been asked to pay a $265 copayment for the ambulance services. 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 ambulance services you received on February 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting.

You asked the Plan to pay for the self-administered drugs. You say that you were advised that you were not allowed to bring in your own medications to the hospital. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the self-administered drugs you received not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth services provided by an out-of-network provider on October 27, 2020.

You asked the Plan to pay for the telehealth services. You say that authorization should not be needed under telemedicine for payment of services rendered. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider.

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 telehealth services provided by an out-of-network provider on October 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a skin graft (15275) provided September 8, 2020.

You asked the Plan to pay for the skin graft. You say that the service was medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.

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 15275 is not supported in the medical record. Specifically, a skin graft was billed however no CPT codes were billed for the skin substitute used. Based on this information, we decided that Medicare rules for coverage of the skin graft have not been met. Therefore, we decided that the Plan does not have to pay for a skin graft (15275) provided September 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on an inpatient basis, in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the abdomen (74150) provided on May 8, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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). Your contract with the Plan clearly says that you must pay a $0 copayment for mammography and ultrasounds. Additionally, you must pay a $150 copayment for all other diagnostic and nuclear medicine radiological services performed at a contracted facility. 

You have been asked to pay a $150 copayment for the diagnostic service provided. 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 computed tomography (CT) scan of the abdomen (74150) provided on May 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve SNF care to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2740) for teeth # 4 and 13.

You asked the Plan to pre-approve the dental services. You say that the enrollee needs crowns for teeth # 4 and 13. The Plan denied your request. The Plan says the crowns are not medically necessary.

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 Plan covers the dental services when the services are medically necessary and reasonable.

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 dental services. Our reviewer says that the crowns are not medically necessary. Our physician reviewer found the provided documentation indicates that there are currently crowns present on # 4 and 13. The reviewer found that there is no evidence as to why the crowns need to be replaced. Therefore, the reviewer found that the replacement crowns for teeth # 4 and 13 are not medically reasonable or necessary.

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 dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740) for teeth # 4 and 13.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.

You asked the Plan to pre-approve Aranesp. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 Aranesp. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the prescriber has not indicated that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or other harm to the enrollee. The elements of the plan's step therapy requirements are not satisfied. The requested service cannot be 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for an eyeglass lens (V2013).

You asked the Plan to pay an additional amount for an eyeglass lens. You say that you would like the Plan to pay the full amount of the item. The Plan denied your request. The Plan says the benefits were applied correctly. The benefit allowance of $125 was applied to the purchase leaving a member responsibility of $54.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to a $125 allowance, then you are responsible for paying the difference.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of an eyeglass lens have not been met. Specifically, the record shows that you had exhausted your eyewear benefit maximum of $125 and are therefore, responsible for paying the remainder of $54.

Therefore, we decided that the Plan does not have to pay an additional amount for an eyeglass lens (V2013).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic office visits (99213, 99202).

You asked the Plan to pay for chiropractic office visits. You say that you should not be responsible for these charges. The Plan denied your request. The Plan says these services are not covered.

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 chiropractic office visits (99213, 99202).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ventilator to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a ventilator to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a ventilator to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted multianalyte assay with algorithmic analysis.

You asked the Plan to pay for the unlisted multianalyte assay with algorithmic analysis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

Review of the file shows that the plan uses Local Coverage Determination (LCD), L37748 to support their denial. However, LCD L37748 is not valid for the provider's billing state of Texas. Therefore, we are unable to use L37748 to substantiate our decision. 

While the enrollee is noted to have melanoma, the documentation does not support that at this enrollee's age, the presumed risk for a positive Sentinel Lymph Node Biopsy (SLNB) based on clinical, histological, or other information is greater than 5%. This means that the unlisted multianalyte assay with algorithmic analysis test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the unlisted multianalyte assay with algorithmic analysis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy for tooth #20 (D3320).

You asked the Plan to pre-approve endodontic therapy for tooth #20. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 endodontic therapy for tooth #20 (D3320).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning (D1110) provided on December 29, 2020.

You asked the Plan to pay for the dental service. You say that you were told that the cleaning was covered. You also say that the clinic suggested this service. The Plan denied your request. The Plan says cleanings are covered twice every plan year. The Plan says that the frequency limit for this service has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage and cleanings are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for cleanings that you received on February 21, 2020, and August 27, 2020. Therefore, we decided that the Plan does not have to pay for the cleaning (D1110) provided on December 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150).

You asked the Plan to pay for the dental service. You say that this visit was for an oral evaluation only. You say that there was no extraction performed. You also say that you were advised there would be no out of pocket cost to you at the time of the visit. The Plan denied your request. The Plan says 1 comprehensive oral evaluation per plan year. The Plan also says that the frequency limit has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage and comprehensive oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received, less than 3 years ago. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered.

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 claim was not filed timely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for these services was not filed until November 21, 2020. A valid Waiver of Liability was not received until December 29, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered.