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

We decided that the Plan does not have to pay for the panoramic X-ray (D0330) provided April 21, 2021.
You asked the Plan to pay for the panoramic X-ray. You say that you would like this claim reprocessed for payment. The Plan denied your request. The Plan says the benefit has been exhausted for this service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the panoramic X-ray services once every five years. We looked at the file and Medicare rules. In this case, the record shows the Plan previously covered panoramic X-ray services within the last five years thereby exhausting the benefit. Based on this information, we decided that the Plan's rules for coverage of the panoramic X-ray have not been met. Therefore, we decided that the Plan does not have to pay for the panoramic X-ray (D0330) provided April 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (CPT code 45378), for the enrollee.
You asked the Plan to pre-approve the colonoscopy. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the same test or a study like it has been done and repeat studies are not supported without results of prior study that show a clear reason for it.
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 colonoscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available documentation in the case file does not support that the requested colonoscopy is medically reasonable and necessary, as the enrollee had a colonoscopy approximately three (3) years ago.
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 colonoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (CPT code 45378), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment without transportation (A0998) provided November 13, 2020.

You asked the Plan to pay for the ambulance response and treatment without transportation. You say that you were unaware you would be responsible for a bill if the transport was not received. The Plan denied your request. The Plan says ambulance treatment without transportation is not eligible for coverage.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on November 13, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without transportation (A0998) provided November 13, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. 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 SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional physical therapy sessions (CPT code 97164), for the enrollee.
You asked the Plan to pre-approve additional physical therapy sessions. You say that this has been recommended by the facility where the enrollee resides at. The Plan denied your request. The Plan says there is no clinical evidence to support the medical necessity of this examination or that the enrollee meets Medicare criteria for this procedure.
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 physical therapy sessions. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee is at a high functional level and does not require the ongoing skills of a professional physical therapy (PT). The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 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 physical therapy sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional physical therapy sessions (CPT code 97164), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve excision of excessive skin services.
You asked the Plan to pre-approve excision of excessive skin services. You say that you have had massive weight loss. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 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 excision of excessive skin services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our reviewer found you have had weight loss causing redundant skin. A letter from the surgeon is provided without records. The primary care medical records do not address the requested procedure. The requested procedure appears to be cosmetic in nature. The provided records do not establish the medically necessity or reasonableness of the requested service, as defined by Medicare rules, for your condition. Therefore, you do not meet criteria for the requested 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 excision of excessive skin services have not been met. Therefore, we decided that the Plan does not have to pre-approve excision of excessive skin services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assisted living visit (CPT code 99335) provided to the
enrollee on October 2, 2020, by an out-of-network provider.
You asked the Plan to pay for the visit. You say that the provider depends on the hospital staff to verify
eligibility and to obtain proper authorization from the enrollee's insurance company. The Plan denied your
request. The Plan says there is no evidence that the provider contacted the plan to verify insurance, current
eligibility, or authorization requirements. The Plan states the provider failed to request prior authorization
before rendering services. The Plan states there is also no evidence of plan directed care and the enrollee was
not receiving skilled services or inpatient services at this time.
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 assisted living visit (CPT code 99335)
provided to the enrollee on October 2, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient visit (99214) provided February 4, 2021.
You asked the Plan to waive the copayment for the outpatient visit. You say that you believe the enrollee is being charged incorrectly. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
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 $15 copayment for physician/practitioner services. The enrollee has been asked to pay a $15 copayment for the outpatient visit. This service falls within the physician/practitioner services benefit category. This means that the enrollee has 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 outpatient visit (99214) provided February 4, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a headspace membership (A9270) for the 2020 Wellness Allowance Benefit.
You asked the Plan to reimburse you for a headspace membership. You say that during the lockdown, you were stressed, and the application helped reduce stress. You also say that your blood pressure has been lowered. The app has soothing sounds and fitness modes for meditation. The Plan denied your request. The Plan says this is not a covered benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that the Plan reimburses up to $300 each calendar year toward your cost of a membership in a qualified health club or fitness facility, covered instructional fitness classes, participation in wellness programs, memory fitness activities, acupuncture and/or covered nutritional counseling sessions with a licensed nutritional counselor or registered dietitian. The Plan's rules for coverage of services for the 2020 Wellness Allowance Benefit have not been met because this service is not a covered benefit. Therefore, we decided that the Plan does not have to reimburse you for a headspace membership (A9270) for the 2020 Wellness Allowance Benefit.
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 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 follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations will be considered medically reasonable and necessary when specific criteria are met. 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 the services are not medically necessary. Our physician reviewer found the documentation does not support that there is radiologic evidence of osteoarthritis of the enrollee's knee, or that there has been failure of at least three months of conservative therapy. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99072) provided on April 5, 2021, and April 12, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Code 99072 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for code 99072. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (99072) provided on April 5, 2021, and April 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for mental health services provided by an outof-
network provider from March 10, 2021, to April 28, 2021.
You asked the Plan to waive the copayment for mental health services. You say that your copayment should
only be $35. The Plan denied your request. The Plan says the correct copayments have been applied.
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 $65
copayment for outpatient mental health care/out-of-network.
You have been asked to pay a $65 copayment for mental health services. The total amount you are being asked
to pay is $455 ($65 x 7 visits =$455). The provider that was seen is out-of-network; therefore, the correct
copayment has been applied to each visit. Mental health services falls within the outpatient mental health
care/out-of-network 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 mental health
services provided by an out-of-network provider from March 10, 2021, to April 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the rehabilitation at a SNF is medically necessary for the enrollee following a stroke. You say that the enrollee cannot ambulate. The Plan denied your request. The Plan says the requirements for approval of continued SNF care have 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received enteral nutrition, medications, and insulin. The enrollee had stable vital signs. The enrollee had routine Foley catheter care and wound care to his buttocks, coccyx, and right ankle. The enrollee received physical therapy, speech therapy, and occupational therapy in the SNF. By the dates in question the enrollee was dependent for functional mobility and activities of daily living. There are no identifiable skilled therapy service needs. While there are identifiable skilled nursing service needs, they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 additional skilled nursing visits.
You asked the Plan to pre-approve additional skilled nursing visits. 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 medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 skilled nursing visits. Our reviewer says that the documentation does not support that the requested home health services are medically reasonable or necessary. Our physician reviewer found there is no recent documentation that would support that the enrollee requires additional skilled nursing services to provide treatment that is medically necessary. The enrollee does not appear to require skilled nursing to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The documentation indicates the enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. There is no recent documentation to indicate the current status of the chronic wound or the plan for wound care. Therefore, the enrollee does not meet criteria for the requested 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 skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 additional skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for dermatology services provided an out-of-network
provider on April 22, 2021.
You asked the Plan to waive the deductible for dermatology services. You say that you have never had to pay
for this before. The Plan denied your request. The Plan says the correct deductible has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $500 deductible which applies to medical services.
The item or service you asked the Plan to waive the deductible for falls within the benefit category medical
services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500
deductible which applies to medical services. This cost sharing is a contractual obligation that had not been met
at the time dermatology services was received on April 22, 2021. The total amount you are being asked to pay
is $233.79. Therefore, we decided that the Plan does not have to waive the deductible for dermatology services
provided by an out-of-network provider on April 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic CGM, includes all supplies and accessories (CPT
code K0553) provided to the enrollee on April 12, 2021.
You asked the Plan to pay for the CGM. You say that the claim should be paid. The Plan denied your request.
The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the CGM have not been met. Review of the documentation
submitted did not include a valid physician order. Therefore, we decided that the Plan does not have to pay for
therapeutic CGM, includes all supplies and accessories (CPT code K0553) provided to the enrollee on April
12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral-complete series of radiographic images (D0210) provided June 14, 2021.
You asked the Plan to pay for the dental services. You say that you were forced to have the complete x-rays by the dentist because he said if you do not get the complete set of x-rays you would need to find another dentist. You did not want them and now you are being billed $198. The Plan denied your request. The Plan says this service is not covered under the Plan benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral-complete series of radiographic images (D0210) provided June 14, 2021.