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

We decided that the Plan does not have to pre-approvethe pneumatic compressor (E0652).You asked the Plan to pre-approvethe pneumatic compressor. You say that you would like reconsideration because this device is medically necessary.The Plan denied your request. The Plan says the record does not include evidence of a trial of a standard compression device.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 pneumatic compressor. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member has not tried and failed the standard compression device and there is no documentation of a trial of self lymphatic drainage.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 pneumatic compressor have not been met.Therefore, we decided that the Plan does not have to pre-approvethe pneumatic compressor (E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the abutment supported crown (D6094), the custom
fabricated abutment (D6057), the unspecified preventive service (D1999), and the 2D oral or facial
photographic imaging (D0350) provided on June 30, 2020.
You asked the Plan to pay for the dental services. You say that you believe that you were the victim of a bait
and switch scam. You say that you were lead to believe that the services you received would be covered if you
purchased the enhanced dental and vision plan. You also say that the services were medically necessary. The
Plan denied your request. The Plan says abutment supported crown is not listed as a covered service. The Plan
says that custom fabricated abutment is not listed as a covered service. The Plan says that the unspecified
preventive service is not listed as a covered service. The Plan also says that the 2D oral or facial photographic
imaging is not listed as a covered 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.
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
abutment supported crown (D6094), the custom fabricated abutment (D6057), the unspecified preventi
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services provided on August 17, 2020.
You asked the Plan to pay for the surgical pathology services. The Plan denied your request. The Plan says
non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for surgical pathology services provided on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 26, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available, and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
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
physician's services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for physician's services provided on November 26, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits with a Licensed Clinical Mental Health
Counselor (LCMHC).
You asked the Plan to pre-approve office visits. You say that you have a previous relationship with this
provider and would like to see them. The Plan denied your request. The Plan says the denial of authorization
for this service is correct, because this provider is not recognized for coverage by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a Licensed Clinical Mental Health Counselor
(LCMHC) is not eligible to enroll in Medicare and is not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of office visits have not been met. Therefore, we decided that the P
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan for calcium scoring for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not covered for screening for heart disease.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically 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 the scan. Our reviewer says that the
requested scan is not medically reasonable or necessary. Our physician reviewer found based on the records,
the enrollee has increased coronary risk. In this setting, screening cardiac CT scanning with calcium scoring is
not recommended and has not been shown to improve cardiac outcome incremental to that achievable based on
treatment guided by standard clinical risk profiling and basic lipid analysis alone.
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 scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve CT scan for calcium scoring for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe computed tomography scan of the soft tissue of the neck (70491), the computed tomography scan of the thorax (71260), and the low osmolar contrast material (Q9967)rendered by the out of network (OON) provider on July 13, 2020.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial.The Plandenied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe computed tomography scan of the soft tissue of the neck (70491), the computed tomography scan of the thorax (71260), and the low osmolar contrast material (Q9967) rendered by the out of network (OON) provider on July 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. 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 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 review indicates that the enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99213) provided on July 20, 2020.You asked the Plan to pay forthe office visit. You say that the services were medically necessary.The Plan denied your request. The Plan says the out-of-network services were not pre-authorized or emergent.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 providerwith the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe office visit (99213) provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-network
provider.
You asked the Plan to pre-approve the medical services. You say that the doctor would like you to see this
provider and you have been paying him out of pocket but need the Plan to approve your visits. The Plan denied
your request. The Plan says the provider is not in-network with your Plan and the services are available to be
rendered by an in-network provider.
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. As the year has changed since the appeal began, please check your
2021 EOC for coverage rules regarding your out-of-network benefits. Therefore, we decided that the Plan does
not have to pre-approve the medical services to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora urethrocystography injection procedure provided on July 23, 2020.You asked the Plan to waive the copayment foroutpatient surgery. You say that this was a diagnostic radiology procedure with no surgical services performed, and you confirmed with the Plan that your copayment would be $50.The Plan denied your request. The Plan says the copayment amount 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 $250 copayment for outpatient surgery at an outpatient hospital. This procedure is considered to be a surgical service; therefore, the outpatient surgery copayment applies to this claim. You also received a radiology procedure at this visit, but you have not been asked to pay any cost-sharing for the radiology service.You have been asked to pay the allowed amount of $201, which is less than the $250 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including 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 fora urethrocystography injection procedure provided on July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vision services (92310, S9986) provided August 5,
2020.
You asked the Plan to pre-approve the vision services. You say that these services should be covered. The Plan
denied your request. The Plan says these vision services are not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan only provides coverage for routine eye exams and glasses or contacts.
We looked at the file and the Plan's rules. The vision services at issue are not covered services. Based on this
information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore,
we decided that the Plan does not have to pre-approve vision services (92310, S9986) provided August 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy.
You asked the Plan to pre-approve physical therapy. You say that you are appealing this denial. The Plan
denied your request. The Plan says the denial of authorization for these services is correct, because further
physical therapy visits are not medically necessary.
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 physical therapy. 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 based on the records provided, there is no documentation that the
requested therapy is generally accepted as specific and effective therapy for your condition. You have
improved with therapy to the point of being able to manage your activities of daily living. Further formal
therapy at this point does not appear likely to achieve any significant improvement in your symptoms or
functional status. Further utilization of a home exercise program appears appropriate at this point.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does
not have to pre-approve additional physical therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup for tooth #3 (D2950).
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan
denied your request. The Plan says this is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core
buildup for tooth #3 (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe annual wellness visit on September 8, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services exceeded the benefit limit.The Plan must follow Medicare rules. Medicare rules say that an annual wellness visit is covered once every 12 months.We looked at the file and Medicare rules. The file shows that you had an annual wellness visit on September 8, 2020. You previously had an annual wellness visit on February 26, 2020 that the Plan approved and paid. The annual wellness visit on September 8, 2020 was performed less than 12 months from your previously covered exam and is not covered by the Plan or Medicare.Therefore, we decided that the Plan does not have to pay forthe annual wellness visit on September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foranti-reflective coating, per lens (V2750), progressive lens, per lens (V2781), contact lens fitting (92310) and sphere, single vision lens (V2100) provided on July 29, 2020.You asked the Plan to pay forcontact lens fitting, progressive lens, anti-reflective coating and sphere single vision lens. You say that the services should be covered.The Plan denied your request. The Plan says the claims were processed correctly.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers $100 towards the purchase of eyewear and eyewear fitting and $75 towards eye exams with refractions. We looked at the file and the Plan's rules. Your purchase exceeded the benefit allowable. Based on this information, we decided that the Plan's rules for coverage of contact lens fitting, progressive lens, anti-reflective coating and sphere single vision lens have not been met. Specifically, you are responsible for the any cost over the allowed amount.Therefore, we decided that the Plan does not have to pay foranti-reflective coating, per lens (V2750), progressive lens, per lens (V2781), contact lens fitting (92310) and sphere, single vision lens (V2100) provided on July 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided from June 6, 2019 to December 19, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plandenied your request. The Plan says the services are not covered as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in a skilled nursing facility setting.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided from June 6, 2019 to December 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 17, 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 December 17,
2019 by a non-participating provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 2, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on September 2, 2020.