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

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on April 16, 2021.
You asked the Plan to pay for the limited oral evaluation (D0140). You say that the dentist assessed the problem as an abscess and recommended that it be pulled. You say that the situation should be covered and allowed. The Plan denied your request. The Plan says D0140 has a frequency limit of one procedure per Plan year.
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, you also have a maximum benefit of one limited oral evaluation every plan year. The Plan paid for a limited oral evaluation provided on January 15, 2021, which exhausted you benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 9, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 physician services provided on February 9, 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 the office visit (99204) rendered by the out-of-network
(OON) provider on January 5, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 service 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 the office visit (99204) rendered by
the out-of-network (OON) provider on January 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic 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 haven't proven that this device is helpful for treatment of arm weakness
following stroke.
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 MyoPro is not known to be effective, based on scientific evidence, professional standards and expert
opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the
long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is
insufficient evidence in the literature that this device will increase participation in bimanual activities. 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 MyoPro Motion G orthotic device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prefabricated abutment (D6056).
You asked the Plan to pre-approve the prefabricated abutment (D6056). The Plan denied your request. The Plan says the services 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. 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 the prefabricated abutment (D6056).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic foot with advanced features (L5981).
You asked the Plan to pre-approve the prosthetic foot with advanced features. You say that the advanced prosthetic is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of foot. 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 prosthetic foot with advanced features. Our reviewer says that the requested prosthetic is not medically necessary. Our physician reviewer found the records do not show that the enrollee's activity level supports a medical need for the advanced K3 foot. Standard foot features can meet the enrollee's needs. 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 prosthetic foot with advanced features have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic foot with advanced features (L5981).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the smart bed (99199) purchased provided on February 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the smart bed. You say that you are appealing the denial for reimbursement for a smart bed that you purchased. The Plan denied your request. The Plan says 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 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 smart bed (99199) purchased provided on February 5, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an office visit provided on February 8, 2021.
You asked the Plan to pay for office visit. You say that you have been having claims successfully paid for many years, and were never notified of a change in benefits. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because services rendered by non-participating providers require prior authorization which was not obtained.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan denied payment for this claim on the basis that this provider is out-of-network with the Plan and authorization was not obtained. However, according to the enrollee's contract with the Plan, enrollees may choose to receive care from out-of-network providers and neither a referral nor prior authorization is needed to obtain services from an out-of-network provider. The Plan provided no other rationale or evidence to support a denial of payment for this service. Therefore, the Plan has not shown that its decision to deny payment is correct or justified according to Medicare rules and the enrollee's contract with the Plan. Therefore, we decided that the Plan has to pay for an office visit provided on February 8, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three crowns (D2750 x3), three prefabricated post and cores in addition to crowns (D2954 x3), and endodontic therapy (D3320).
You asked the Plan to pre-approve the crowns, prefabricated post and cores, and endodontic therapy. You say that the provider told you that your teeth would need to be extracted if you do not receive the root canal. The Plan denied your request. The Plan says these services are not covered benefits under your plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plans 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 three crowns (D2750 x3), three prefabricated post and cores in addition to crowns (D2954 x3), and endodontic therapy (D3320).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on January 2, 2021.
You asked the Plan to waive the copayment for emergency care. You say that you had a serious infection that required surgery and request that the emergency room copayment be waived. 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 an $85 copayment for emergency care. You have been asked to pay an $85 copayment for emergency care. Emergency care falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on January 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Stress TTE Complete, with Doppler Echo Exam of
the Heart, and Doppler Color Flow add-on.
You asked the Plan to pre-approve the Stress TTE Complete, with Doppler Echo Exam of the Heart, and
Doppler Color Flow add-on. You say that you would like reconsideration based on the records submitted. The
Plan denied your request. The Plan says the requested service 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 pre-approve the Stress TTE Complete, with Doppler
Echo Exam of the Heart, and Doppler Color Flow add-on. Our reviewer says that the requested items/services
are not considered medically reasonable and necessary in this case. Our physician reviewer found The case file
does not contain documentation that the enrollee was having new, recurrent, or worsening cardiac symptoms,
including otherwise unexplained angina equivalent symptoms. The enrollee did not have a new or previously
unrecognized uninterpretable electrocardiogram.
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 Stress TTE Complete, with Doppler Echo Exam of the Heart, and Doppler
Color Flow add-on have not been met. Therefore, we decided that the Plan does not have to pre-approve the
Stress TTE Complete, with Doppler Echo Exam of the Heart, and Doppler Color Flow add-on.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on January 8, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that you were not consulted about the ambulance services nor the cost. 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 $300 copayment for ambulance services. You have been asked to pay a $300 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on November 19, 2020 and billed under code G0483.
You asked the Plan to pay for code G0483. You say that this claim should be paid. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. The claim error is an incorrect POS code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes.
In this case, the claim cannot be paid as billed due to an error with the POS code reported. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on November 19, 2020 and billed under code G0483.
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 from February 3, 2021, to February 9, 2021.
You asked the Plan to pay for the self-administered drugs. You say that no one told you that you would be responsible for the cost of self-administered drugs. You also say that had you known, you would have taken your 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 drugs you received are 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 from February 3, 2021, to February 9, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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. The Plan denied your request. The Plan says IRF admission is not medically necessary.
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 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 congestive heart failure. Medical problems 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-preferred continuous glucose monitor.
You asked the Plan to pre-approve the specific monitor. You say that this is medically necessary. The Plan
denied your request. The Plan says there is a preferred product line.
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 specific monitor. Our reviewer says
that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is no reason given why the enrollee would not be able to use the plan's preferred brand.
The preferred brand has an alert/alarm system much like the requested non-preferred brand. While there are
some insulin pumps that work alongside the non-preferred monitor, the enrollee is not on an insulin pump.
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 specific monitor have not been met. Therefore, we decided that the Plan
does not have to pre-approve a non-preferred continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for compression stockings purchased on August 19, 2020.
You asked the Plan to pay for compression stockings. You say that these stockings are necessary to treat
lymphedema The Plan denied your request. The Plan says these stockings are not covered by the Plan or by
Medicare for your condition.
The Plan must follow Medicare rules. Medicare does not cover compression stockings for treatment of
lymphedema alone. The record does not show that you have open venous stasis ulcers or a qualifying wound.
This means that you do not have a medical condition for which compression stockings can be covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for compression stockings purchased
on August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network neurosurgeon.

You asked the Plan to pre-approve the referral. You say that you are unable to walk straight. The Plan denied your request. The Plan says you are contractually required to obtain this service 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 neurosurgeon.