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

We decided that the Plan does not have to pre-approve complete upper dentures (D5110) and a partial lower
denture (D5214).
You asked the Plan to pre-approve complete upper dentures and a partial lower denture. You say that the items
are necessary. The Plan denied your request. The Plan says the benefit has been exhausted.
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 complete
upper dentures or partial dentures once every five years.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of complete upper dentures and a partial lower denture have not been met. Specifically, you received
complete upper dentures and a partial lower denture on October 1, 2020. You are not eligible for plan coverage
at this time. Therefore, we decided that the Plan does not have to pre-approve complete upper dentures (D5110)
and a partial lower denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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. 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis.
The requested Vertiflex Superion spacer is considered experimental/investigational in nature, as more research
is needed to show safety and efficacy. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on March 23, 2021.
You asked the Plan to waive the copayment for an EGD. You say that you disagree with the 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 a $150 copayment for outpatient surgery and other medical services provided at ambulatory surgical centers. You received an EGD at an ambulatory surgical center on March 23, 2021. An EGD is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $150 copayment.
You have been asked to pay a $150 copayment for an EGD. An EGD falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 an EGD provided on March 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 1, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because you did not want to go to the hospital lab due to COVID-19. The Plan denied your request. The Plan says these services were not urgent, emergent or approved in advance.
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 laboratory services provided on October 1, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation treatment provided on March 4, 2021.
You asked the Plan to waive the coinsurance for radiation treatment. You say that you could have done surgery for free but was advised of radiation treatment. You say that you were never told there was 20% coinsurance. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance per visit for radiation therapy.
You have been asked to pay $8.36, which is 20% of the allowed amount for the radiation treatment. The allowed amount is $41.78 (20% x $41.78 = $8.36). Radiation treatment falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 for radiation treatment provided on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four gingival irrigations (D4921 x4).
You asked the Plan to pre-approve the gingival irrigations. You say that you need the gingival irrigation before
you get the deep cleaning and cannot afford the out of pocket expense. The Plan denied your request. The Plan
says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve four
gingival irrigations (D4921 x4).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.
You asked the Plan to pre-approve home health aide services. You say that you need help reading canned food labels and arranging medications. The Plan denied your request. The Plan says medical records received do not indicate that you are confined to your home or that you have received an order from your physician for any type of skilled nursing care or therapy.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. We looked at the file and Medicare rules. The physician order is not for skilled nursing care or therapy. Custodial care is not covered. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

Explanation of decision
We decided that the Plan does not have to pre-approve the first 15 minutes of IV moderate (conscious)
sedation/analgesia (D9239) and three subsequent 15-minute increments of IV moderate (conscious)
sedation/analgesia (D9243 x3).
You asked the Plan to pre-approve the IV moderate (conscious) sedation/analgesia. You say that you are
allergic to local anesthetics and these services would be the alternative. The Plan denied your request. The Plan
says these services are not covered under the terms of your policy.
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
first 15 minutes of IV moderate (conscious) sedation/analgesia (D9239) and three subsequent 15-minute
increments of IV moderate (conscious) sedation/analgesia (D9243 x3).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a negative pressure wound therapy (NPWT) pump.
You asked the Plan to pre-approve a NPWT pump. 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 a NPWT pump and supplies will be denied as not reasonable and necessary under certain circumstances.
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 NPWT pump. Our reviewer says that the services are not medically necessary. Our physician reviewer found records do not show the wound has significantly improved with NPWT pump treatment. In fact, the wound size appears stable. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a NPWT pump have not been met. Therefore, we decided that the Plan does not have to pre-approve a negative pressure wound therapy (NPWT) pump.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. 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 must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric adjustable bed frame (queen bed).
You asked the Plan to pre-approve the bed. You say that you literally spent four hours examining the bed and fell asleep on the bed in the store. The Plan denied your request. The Plan says mattress are covered only where a hospital bed is medically necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules say that a mattress is only covered for a medically necessary hospital bed. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. A mattress can
only be covered for a hospital bed. Therefore, we decided that the Plan does not have to pre-approve an electric adjustable bed frame (queen bed).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array.
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array. 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 coverage of PNS trials requires that patients meet specific criteria. 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 percutaneous implantation of neurostimulator electrode array. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation of plain x-rays of the shoulders, magnetic resonance imaging (MRI)
of the shoulders, any prior surgery intervention or consultation or Physical Therapy. The request 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 percutaneous implantation of neurostimulator electrode array have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network benefit exception for counseling to be rendered by the requested 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 an in-network benefit exception has not been approved for the requested provider as they do not provide care to enrollees who have Medicare insurance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that enrollees may get their care from an out-of-network provider, however, in most cases that provider must be eligible to participate in Medicare. The requested provider in this case is an out-of-network provider that does not provide care to members who are enrolled in Medicare. The Plan contract states that you can receive care from an out-of-network provider, however, in most cases that provider must be eligible to participate in Medicare. The requested provider does not participate in the Medicare program.
The Plan has authorized an in-network benefit exception for counseling services with another out-of-network
provider who uses American Sign Language (ASL). Therefore, we decided that the Plan does not have to preapprove
an in-network benefit exception for counseling to be rendered by the requested out-of-network (OON)
provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the health problem.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
You asked the Plan to pre-approve the compression stockings. You say that you thought everything related to your condition would be covered, and if you do not use these sleeves your arms will swell really bad. The Plan denied your request. The Plan says these items are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6545 are only covered for treatment of an open venous stasis ulcer meeting qualifying wound requirements.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp for an automobile.
You asked the Plan to pre-approve wheelchair ramp. You say that you need this to enter your vehicle. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this wheelchair ramp is not a Medicare-covered benefit.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp for an automobile.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70460) provided on July 26, 2020.
You asked the Plan to pay for a CT scan. You say that this procedure was performed. The Plan denied your
request. The Plan says this is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70460
has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for a computed tomography (CT) scan (70460) provided on July 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Coolief, radiofrequency ablation (RFA) treatment.
You asked the Plan to pre-approve Coolief. You say that the enrollee's pain level is 10 out of 10. You say that the radiofrequency treatment is used to offer longer lasting pain relief. You also say that Coolief is Food and Drug Administration (FDA) cleared, effective April 13, 2017. The Plan denied your request. The Plan says Coolief is considered experimental and investigational for the treatment of knee osteoarthritis.
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 Coolief. Our reviewer says that the requested Coolief RFA treatment is not considered medically reasonable and necessary in this case. Our physician reviewer found Coolief RFA is considered experimental. The reviewer found that RFA of the genicular nerves is considered experimental and investigational as there are ongoing clinical trials to determine its role in the management of osteoarthritis of the knee. Therefore, the reviewer found that the requested Coolief RFA treatment 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 Coolief have not been met. Specifically, the requested treatment is considered experimental and investigational, and is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve Coolief, radiofrequency ablation (RFA) treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on March 15, 2021.
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 the enrollee did not have prior authorization for out of network care.
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 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 to the enrollee on March 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on December 1, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says the claim correctly processed. Payment is calculated taking into consideration the payment made by the auto carrier and the Plan's allowable amount. Combined, the auto carrier payment and the Plan's payment should not exceed the Medicare allowable amount of $450.29. The auto carrier paid $1,000.00 therefore, the Plan's responsibility is $0.00
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has processed the claim correctly. Therefore, we decided that the Plan does not have to pay for ambulance services provided on December 1, 2020.