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

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140), intraoral X-rays (D0220), and core buildup (D2950) provided on July 15, 2020, by a provider that has opted out of Medicare.You asked the Plan to pay forthe limited oral evaluation, intraoral X-rays, and core buildup. You say that you believe that the dental care you received should be paid for by the Plan.The Plan denied your request. The Plan says they cannot issue payment for services performed by an opt-out provider.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140), intraoral X-rays (D0220), and core buildup (D2950) provided on July 15, 2020, by a provider that has opted out of Medicare
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinjection services.You asked the Plan to pre-approveinjections. 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 follows Medicare rules. Medicare rules say that neurolysis facet nerve is only covered for certain indications.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 injections. Our reviewer says that the documentation does not support that the requested injection services are medically reasonable or necessary. Our physician reviewer found the enrollee has back pain and spondylosis without myelopathy or radiculopathy. The enrollee had one other medial branch block on November 16, 2020 with reported 80% relief. No other facet-related procedures have been performed in the last year. The provided medical records do not support that the enrollee has satisfied the LCD requirements. 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 injections have not been met.Therefore, we decided that the Plan does not have to pre-approveinjection services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K2 prosthesis and addition to lower extremity,
endoskeletal system, above knee, universal multiplex system, friction swing phase control (L5616).
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied
your request. The Plan says that the requested K2 prosthesis exceeds the member's needs and cannot be
covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules also state that a single addition code can fully describe a complete kneeshin
system and thus the use of two codes (L5610, L5611, L5613, L5616, L5810, L5811, L5812, L5814,
L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840) would be considered incorrect coding
(unbundling)
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 a K2 prosthesis. Our reviewer says that
the requested K2 prosthesis is not considered medically reasonable and necessary in this case. Based on the
available records you are a K1 ambulator and does not meet criteria for the K2 device. Our physician reviewer
found that your condition does not meet Medicare criteria for a K2 prosthesis.
We looked at this physician's review, the file, and Medicare rules. The file indicates the plan has approved the
addition code L5812 for a complete knee-shin system and cannot cover a second addition code of L5616.
Based on this information, we decided that Medicare rules for coverage of a K2 prosthesis have not been met.
Therefore, we decided that the Plan does not have to pre-approve a K2 prosthesis and addition to lower
extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control (L5616).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 5, 2019 by a
non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-participating 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 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. 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 medical services provided on November 5,
2019 by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis (L1833) and suspension sleeve (L2397) provided July 21, 2020.You asked the Plan to pay forthe orthoses. You say that please review the attached documents with information to determine this enrollee's eligibility for claim reimbursement.The Plan denied your request. The Plan says the records do not support the billed service.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. In this case, there were no claims from the ordering/ referring physician within the last 6 months prior to the date of the service. Therefore, without a face-to-face encounter, the ordering physician couldn't gather the information associated with diagnosing, treating, or managing the clinical condition for which the orthoses were ordered. The record shows that thePlan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay forthe knee orthosis (L1833) and suspension sleeve (L2397) provided July 21, 2020
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the notes do not support medical need.
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 the services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found the documentation
doesn't support that the enrollee requires skilled nursing services or skilled rehab services to provide treatment
that is medically necessary. The enrollee does not require skilled nursing or rehab services to effectively
provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance
program to maintain the member's condition and/or prevent deterioration. The enrollee has been medically
stable without any recent exacerbations of chronic medical problems or hospitalizations. She received skilled
care after discharge from a skilled nursing facility and her function has improved however further skilled home
health care is not medically necessary. Furthermore, she has family support and does not require a home health
aide.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve additional home health services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea special color, seat lift, USB Charger, bag hooks and light kit, additional foot plates, additional parts for the seat belt, additional shoulder traps, and cushions.You asked the Plan to pre-approvethese power wheelchair accessories. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested items are not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.Apower seat elevation feature (E2300) is non-covered because they are not primarily medical in nature.The itemsat issue in this appealincluding the special color, USB charger, bag hooks, and light kit donot serve a purpose that is primarily medical in nature. Theseitems are available to the general public and would be helpful even to those who are not sick or injured.The requested power seat elevation feature is non-covered. In addition, the approved wheelchair and accessories include shoulder straps including mounting hardware, Therefore, additional shoulder straps are not needed. Wheelchair seating and back cushion codes are all-inclusive and have already been approved and cannot be separately approved.Seat modifications, seat cushion covers, seat cushion overlays, back covers, back cushion overlays, footplates, hardware for custom seating items and strap guides already included with the requested power wheelchair.Therefore, we decided that the Plandoes not have to pre-approvea special color, seat lift, USB Charger, bag hooks and light kit, additional foot plates, additional parts for the seat belt, additional shoulder traps, and cushions
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 1, 2020, by an OON provider.You asked the Plan to pay fora domiciliary or rest home visit. You say that these medically necessary services were provided to the enrollee in good faith.The Plan denied your request. The Plan says rules for payment have not been met.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care andpre-approved care.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. 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 forthe medical services provided on June 1, 2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fordurable medical equipment provided to the enrollee on March 25, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order, an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery; therefore, the billed services cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Medicare rules say that DME supplies must be provided with a proof of delivery and a physician order.We find that the denied codes are not supported in the medical record. Specifically, the required documentation pertaining to the proof of delivery and physician order of these supplies was not provided. 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 fordurable medical equipment provided to the enrollee on March 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveabutment supported crowns (D6058) for teeth # 31 and 32, and surgical placement of implants (D6010) for teeth # 31and 32.You asked the Plan to pre-approvethe dental services. You say that you are appealing the crown portion of the implant and not the implant abutment. You say that these are 2 separate services done at separate times. You say that the Plan has failed to demonstrate a substantial difference between a crown over a natural tooth and a crown over an implant.The Plan denied your request. The Plan says abutment supported crowns are not listed as covered services. The Plan says that surgical placement of an implant is not listed as a covered service either. The Plan also says that any services not listed 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-approveabutment supported crowns (D6058) for teeth # 31 and 32, and surgical placement of implants (D6010) for teeth # 31 and 32
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forMedicare Part B drugs provided on December 30, 2019.You asked the Plan to waive the coinsurance forMedicare Part B drugs. You say that you disagreewith the increase in charges.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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay $1,367.08, which is less than the 20% coinsurancefor Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 coinsurance forMedicare Part B drugs provided on December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foran eye refraction exam (92015) performed on July 3, 2019.You asked the Plan to pay foran eye refraction exam. You say that the refraction services should be covered and paid.The Plan denied your request. The Plan says rules for payment have not been met.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for an eye refraction exam was not filed until September 15, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay foran eye refraction exam (92015) performed on July 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadditional power wheelchair accessories (E2377, E2313, E2311).You asked the Planto pre-approvethe accessories. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no medical need to control the features through a joystick.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 accessories. Our reviewer says that the requested accessories arenot considered medically reasonable and necessary in this case. Our physician reviewer found the expandable harness (E2313), the (E2311) electronic connection, and the (E2377) expandable controller are not medically necessary. The documentation does not reveal that the enrollee needs an expandable controller to operate other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.), non-proportional input devices (e.g., sip and puff, head array, etc.), or to operate 3 or more powered seating actuators through the drive control. The documentation does not reveal the enrollee needs the expandable controller to operate a separate display (i.e., for alternate control devices),other electronicdevices (e.g., control of an augmentative speech device or computer through the chair's drive control), or for an attendant control. The enrollee has sufficient functional ability (independent in feeding and grooming) to operate any power options throughtheir own individual 
switches.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 accessories have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadditional power wheelchair accessories (E2377, E2313, E2311).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe fine needle aspiration procedure (76942, 10005, A4215, A4209, 99000)  to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe procedure. You say that please reconsider the decision and approve this appeal request.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 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-approvethe fine needle aspiration procedure (76942, 10005, A4215, A4209, 99000)  to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator provided on July 9, 2020.
You asked the Plan to pay for the neuromuscular stimulator, electronic shock unit (E0745). You say that a
pneumatic compression device was medically necessary. The Plan denied your request. The Plan says criteria
for the neuromuscular stimulator was not met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. We looked at the file and Medicare rules. The claim is for a second or third month rental. There is no physician documentation of the effectiveness of the device. Based on this information, we decided that Medicare rules for
coverage of neuromuscular stimulator, electronic shock unit chair (E0745) have not been met. Therefore, we
decided that the Plan does not have to pay for the neuromuscular stimulator provided on July 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost forthe office visit, Part B drugs, therapeutic injections and infusions provided on March 9, 2020.You asked the Plan to waive the cost forthe office visit, Part B drugs, therapeutic injections and infusions. You say that you were not told there was a $10,000 out of pocket cost for services. You say that you already paid your $3,400 out-of-pocket maximum and shouldn't owe this.ThePlan denied your request. The Plan says the cost share 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 $20 copayment for services obtained from aspecialist, 20% coinsurance for each Medicare-covered Part B drug and 20% coinsurance for each Medicare-covered Part B chemotherapy drug and the administration of that drug. You have been asked to pay a total of $1,466.15 for the office visit, Part B drugs, therapeutic injections and infusions
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) care.You asked the Planto pre-approvethe SNF care. You say that you feel that you require SNF care.The Plandenied your request. The Plansaysyou have used up your 100-day SNF benefit for this benefit period.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from August 14, 2020, through November 29, 2020. The Plan has covered 100 days of SNF care.Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60days in a row.Therefore, we decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 21, 2020, by an OON
provider.
You asked the Plan to pay for a provider office visit. You say that this claim should be reconsidered. The Plan
denied your request. The Plan says rules for payment have not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 has network providers
available who can provide 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 medical services provided on July 21, 2020, by
an OON provider.