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

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 12, 2020.
You asked the Plan to pay for the prophylaxis. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, prophylaxis (D1110) and are limited to two procedures per plan year. The record shows that you received a prophylaxis (D1110) on February 27, 2020, and July 8, 2020 and your prophylaxis (D1110) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the health problem.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device is experimental. More research is needed to show the safety and efficacy of the interspinous process spacer device. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthopedic consult (99204, 99214, 99244) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve an OON orthopedic consult. You say that you need to go out-of-network because network providers are not performing elective surgeries. The Plan denied your request. The Plan says these services are available in-network and in-network providers are currently accepting elective surgeries.

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 an orthopedic consult (99204, 99214, 99244) 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 implant placement tooth 29 and 30, custom abutment teeth 29 and 30 and abutment supported porcelain fused to metal crown (noble metal) teeth 29 and 30.
You asked the Plan to pre-approve these dental services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implant placement tooth 29 and 30, custom abutment teeth 29 and 30 and abutment supported porcelain fused to metal crown (noble metal) teeth 29 and 30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network durable medical equipment supplier.
You asked the Plan to pre-approve these services. You say that you need a new prosthesis and supplies. The Plan denied your request. The Plan says the services are available from network providers.
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 referral to an out-of-network durable medical equipment supplier.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on July 16, 2020.
You asked the Plan to pay for the office visit. You say that the enrollee was recommended to this provider for treatment and evaluation. You say that if you are not accepted as a provider you will have to discharge the patient. The Plan denied your request. The Plan says care must be received from 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on July 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain fused to high metal crown for tooth 1 and 15.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the 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 pre-approve a porcelain fused to high metal crown for tooth 1 and 15.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit rendered on September 3, 2020.
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 you exhausted the benefit limit.
The Plan must follow Medicare rules. Medicare rules say that an annual wellness visit is covered once every 12 months. We looked at the file and Medicare rules. The file shows that you had an annual wellness visit on March 2, 2020 that the Plan covered. The annual wellness visit on September 3, 2020 was performed less than 12 months from your previously covered annual wellness visit. Therefore, we decided that the Plan does not have to pay for the annual wellness visit rendered on September 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services.

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 procedure codes 63081 and 22854 are not supported.

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 63081 is vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment. The definition of code 22854 is insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure).

We find that CPT codes 63081 and 22854 are not supported in the medical record. Specifically, there is no documentation of insertion of an intervertebral biomechanical device to support code 22854. There is no documentation of a vertebral corpectomy to support code 63081. 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 pay for the surgical services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three units of ForeSee Home Monitoring (home vision monitoring) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the home vision monitoring. You say that the enrollee does not have the option to visit an in-network provider, as you are the only provider in the world to render these services. The Plan denied your request. The Plan says the requested service is considered experimental. Enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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. Medicare rules say that experimental and investigational devices are not covered. The requested provider in this case is not a network provider with the Plan. 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 three units of ForeSee Home Monitoring (home vision monitoring) to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy and the upper GI endoscopy provided on September 29, 2020.
You asked the Plan to waive the copayment for the colonoscopy and the endoscopy. You say that you were told there would only be one copayment for both surgeries because they were being done at the same time. You say you should not be charged a second copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $245 copayment for surgery services provided at an in-network ambulatory surgical center. You have been asked to pay a $245 copayment for the colonoscopy and the endoscopy. The colonoscopy and the endoscopy fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were charged one copayment for both procedures. 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 colonoscopy and the upper GI endoscopy provided on September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit.

You asked the Plan to waive the copayment for the office visit. You say that you thought you were entitled to an exam every two years. You say that you want to recover the $35 you paid. 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 $35 copayment for each specialist visit.

You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show an office visit was billed due to cataracts being checked. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour test strips.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from the preferred provider.

The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers for durable medical equipment and supplies. 

We looked at the file and Medicare rules. The requested services are test strips from Contour. This is not a preferred provider with the Plan. The services are available from the Plan's preferred provider. Therefore, we decided that the Plan does not have to pre-approve Contour test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic parenteral drug provided on November 18, 2020.
You asked the Plan to pay for the therapeutic parenteral drug. You say that you believe this service should be covered. The Plan denied your request. The Plan says you have met your maximum allowance for dental 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 Plan offers a $1,000 allowance for covered dental services. The contract clearly states that you will be responsible for 100% of the charges beyond the $1,000 allowance. The record shows that you met the annual maximum benefit while processing this claim for the November 18, 2020 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the therapeutic parenteral drug provided on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrocardiogram (93010) and outpatient visit (99215) provided on November 3, 2020.
You asked the Plan to pay for the electrocardiogram and outpatient visit. You say that you would like reconsideration because the Plan is the primary insurer. The Plan denied your request. The Plan says an explanation of benefits of other insurance is required for further process of the appeal.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested for the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the electrocardiogram and outpatient visit until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for electrocardiogram (93010) and outpatient visit (99215) provided on November 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses (L1833, L2397).

You asked the Plan to pay for the knee orthoses. You say that you would like reconsideration because the knee
orthoses are medically necessary. The Plan denied your request. The Plan says this provider is not listed in the
member's claims history.

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 knee orthoses. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is insufficient credible documentation of an evaluation of the enrollee, and there is
insufficient credible objective documentation of joint laxity.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the knee orthoses have not been met. Therefore, we decided that the Plan does
not have to pay for the knee orthoses (L1833, L2397).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) and therapeutic exercises (97110) provided on October 30, 2020.
You asked the Plan to pay for the office visit and therapeutic exercises. You say that you would like reconsideration because you received manual manipulation of the spine which is a covered benefit. The Plan denied your request. The Plan says the office visit and therapeutic exercises are not covered benefits.
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 the office visit (99203) and therapeutic exercises (97110) provided on October 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.
You asked the Plan to pre-approve Hyalgan. You say that your doctor says that Hyalgan will be effective for the arthritis-associated pain in my shoulder. The Plan denied your request. The Plan says that none of the accepted compendia consider the use of this drug for your illness as a medically accepted FDA approved or off label use.
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 Hyalgan. Our reviewer says that Hyalgan is not medically reasonable and necessary. The requested use of Hyalgan is not FDA-approved for your shoulder diagnosis. The use of Hyalgan is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found that your condition does not meet Medicare criteria for Hyalgan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the general health panel provided on November 7, 2020.
You asked the Plan to pay for the general health panel. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-covered code. You have requested payment for services billed under code 80050. Medicare does not cover or pay for services billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel provided on November 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on September 11, 2020.
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 there is no valid physician order.
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 pay for the lumbar-sacral orthosis rendered on September 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve unlimited routine transportation for dialysis services.

You asked the Plan to pre-approve unlimited routine transportation. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says your request exceeds the allowable transportation benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at your request, the records in the case file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the Plan contract states that this benefit covers unlimited rides to your primary care provider's office. Additionally, you are covered up to 30 one-way rides per year to other health care related locations, such as to the pharmacy or specialist appointments. Your request for unlimited transportation for treatment by the dialysis clinic exceeds the allowable transportation benefit. Therefore, we decided that the Plan does not have to pre-approve unlimited routine transportation for dialysis services.