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

We decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee on
August 18, 2020.

You asked the Plan to pay for this claim. You say that this equipment was provided to the enrollee for use
during and after surgery. The Plan denied your request. The Plan says Medicare billing criteria are not met.

The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers.

This equipment was used during and after a surgical procedure by the facility. Payment for this service would
have been included under the facility claim. Payment to you for this service is the responsibility of the facility
or hospital. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device
provided to the enrollee on August 18, 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 a review of the current medical literature indicates that this service is considered experimental and investigational.
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 current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis, including the planned level of implantation L4-5. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and which have not been adequately addressed in the medical records. There is imaging evidence of mild retrolisthesis L5 over S1, 5mm (with no discussion of spinal instability on flexion/extension films.) There is imaging evidence of levoscoliosis at the L2-3, with no documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis. Overall, there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L4-5 is not medically reasonable or necessary. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a biopsy procedure (38505) provided on April 14, 2021.
You asked the Plan to waive the copayment for an outpatient procedure. You say that you were told the charge would be $75. After receiving the bill, you do not understand why the bill is so much higher. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 each Medicare-covered outpatient hospital service, including observation, outpatient surgery or procedure. You have been asked to pay a $300 copayment for an outpatient procedure. The records show you had a biopsy done at an outpatient hospital. The EOC confirms that $300 is the required copayment for this service. An outpatient biopsy procedure falls within the outpatient hospital 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 a biopsy procedure (38505) provided on April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0220) provided on March 17, 2021.
You asked the Plan to pay for an intraoral periapical radiographic image. You say that the service was necessary. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every calendar 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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an intraoral periapical radiographic image have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on March 9, 2021. Therefore, we decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0220) provided on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3-surface fillings (D2332 x 4), the 2-surface fillings (D2391 x 2), and the single-surface filling (D2392) provided on April 8, 2021.
You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that fillings were fully covered. You also say that none of the fillings were covered. The Plan denied your request. The Plan says 2 fillings are covered per calendar year. The Plan says that the frequency limit has been exceeded. The Plan says that correct information was given to the provider on both calls. The Plan also says that the office did not have questions about fillings on either call.
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 fillings are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for the fillings for teeth # 24 and 25 that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the 3-surface fillings (D2332 x 4), the 2-surface fillings (D2391 x 2), and the single-surface filling (D2392) provided on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
You asked the Plan to pre-approve the maxillary partial denture. You say that you were not able to have this service provided the first time because the Coronavirus hit, and your dentist office had closed for a while. The Plan denied your request. The Plan says this service is only covered 1 time in a 60 month period. The Plan also says that you have already had 1 of these services done in that time period.
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 are limited to 1 complete or partial denture every 5 years. The record shows that you received a maxillary partial denture (D5213) on March 16, 2020 and your maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on November 19, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim must be submitted to Original Medicare first. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on November 19, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on August 18, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim must be submitted to Original Medicare first. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on August 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
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 medically necessary.
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 there is no medical need for the multiple power options included with the requested group 3 power wheelchair. There is no current diagnosis or history of pressure ulcers. The enrollee does not utilize intermittent catheterization for bladder management. There is no significant increased tone or spasticity. The enrollee does not need the additional accessories. 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 group 3 power wheelchair and accessories for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate tablets.
You asked the Plan to pre-approve Methotrexate tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Methotrexate tablets are not covered under the enrollee's Medicare Part B benefit.
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 pre-approve Methotrexate tablets.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on January 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim originally denied for not meeting coding standards, but the services are not authorized.
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 laboratory work provided on January 26, 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 implantable neurostimulator, pulse generator (L8679).
You asked the Plan to pre-approve the neurostimulator device. You say that the enrollee has tried and failed
conservative care and medication therapies. Based on history and diagnoses, the provider is recommending the
neurostimulator to decrease pain. The Plan denied your request. The Plan says this is not a covered benefit. The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case.
The rules also say that services that are not medically necessary are not covered. The rules also say that
experimental and investigational devices are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, electroacupuncture is not unproven. It's efficacy has
not been established. Therefore, we decided that the Plan does not have to pre-approve implantable
neurostimulator, pulse generator (L8679).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on March 30, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you did not have lab services on this date. The Plan denied your request. The Plan says you were charged this copayment 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 $10 copayment for lab services. You have been asked to pay a $10 copayment for the lab services. Medical records from this date of service clearly show that you had a lab service on this date and the specimen was taken at 8:46am. 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 lab services you received on March 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments charged for the magnetic resonance imaging (MRI) and computed tomography (CT) scan you received on January 4, 2021.
You asked the Plan to reduce the copayments charged for the MRI and CT scan. You say that because these tests were done at the same time, there should only be one copayment. The Plan denied your request. The Plan says two separate copayments were charged correctly because you had two separate services.
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 $275 copayment for each diagnostic radiology service. You have been asked to pay a $275 copayment each for the MRI and CT scan. The MRI and CT scan fall within the diagnostic radiology service benefit category. This copayment is a per-service copayment, not a per
date of service copayment. 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 reduce the copayments charged for the magnetic resonance imaging (MRI) and computed tomography (CT) scan you received on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office consultation to be rendered by the out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional speech therapy.
You asked the Plan to pre-approve additional speech therapy. You say that additional speech therapy is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional speech therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found that based on review of the limited available records, you do not meet CMS coverage criteria for the requested continued services with a diagnosis of Dementia. It is not clear the duration of your dementia and your baseline cognitive deficits. The medical documentation does not support the need for requested ongoing speech therapy services. Based on review of the records, you do not meet the CMS coverage criteria for requested speech therapy services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional speech therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve additional speech therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on March 16, 2021.
You asked the Plan to pay for chiropractic services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says any services that are not coded as manual manipulation of the spine 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 services provided on March 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Qutenza.
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 medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has idiopathic neuropathy.
Qutenza is not FDA-approved for treatment of this diagnosis and is considered investigational in nature.
Qutenza is therefore not safe and effective and reasonable and medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Qutenza.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on March 8, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the home visit. You say that the service was medically necessary. You say the provider was inaccurately flagged as out-of-network. 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 home visit provided on March 8, 2021 by an out-of-network (OON) provider.