Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a physician visit provided on December 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for a physician visit. You say that these services were medically necessary. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider. The Plan says that the referring provider is out-of-network.
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 a physician visit provided on December 21, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device surgery.

You asked the Plan to pre-approve Vertiflex Superion device surgery. You say that you disagree with the plan's
denial. 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 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 Vertiflex Superion device surgery. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found you spinal stenosis with back pain and neurogenic claudication. The
Vertiflex 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 Vertiflex Superion device surgery have not been met. Therefore, we decided
that the Plan does not have to pre-approve Vertiflex Superion device surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical supplies provided on September 1, 2020, by an
OON provider.
You asked the Plan to pay for medical supplies. You say that these supplies were medically necessary. The
Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 medical supplies provided on September 1, 2020,
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 24, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you do not know if the provider should be considered a specialist and feel that you should only owe a regular doctor's office visit copayment. 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 $45 copayment for specialist services. The record shows that the provider you saw on March 24, 2021, is considered a specialist. Therefore, you are responsible to pay the $45 copayment. You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on March 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425,
A0427) received February 17, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that since it was an
emergency, you should not be billed as you were being picked up by the fire department, not an ambulance.
The Plan denied your request. The Plan says the requested services were billed as ambulance services by an
ambulance provider. The correct cost share applied to the claim.
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 $350
copayment for Ambulance Services.
You have been asked to pay a $350 copayment for the ambulance transportation. The ambulance transportation
falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
the ambulance transportation (A0425, A0427) received February 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0274, D0230, D0120, D0220) received March 12, 2021 from the out-of-network provider.

You asked the Plan to pay for the dental services (D0274, D0230, D0120, D0220). You say that the Plan should pay for the requested services. The Plan denied your request. The Plan says you must use a participating network provider for your dental 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. The Plan contract states you must use a network provider for your dental benefits. You received these services from an out-of-network provider.

Therefore, we decided that the Plan does not have to pay for the dental services (D0274, D0230, D0120, D0220) received March 12, 2021 from the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the standard frames (V2020) and spherocylinder bifocal
lenses (V2203) provided March 1, 2021.

You asked the Plan to pay for the frames and lenses. You say that you have gotten glasses yearly in the past
and were not made aware that you could only get frames every two years. The Plan denied your request. The
Plan says you are only covered for standard lenses and frames every two years and eye wear was previously
covered less than two years ago.

Medicare generally does not cover routine vision and eye wear services. However, the Plan offers a routine
vision and eye wear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers standard frames and lenses once every two years.

We looked at the file and the Plan's rules. In this case the Plan provided documentation showing that frames
and lenses were previously covered in January 2020. Based on this information, we decided that the Plan's
frequency limit for coverage of the frames and lenses has been exceeded. Therefore, we decided that the Plan
does not have to pay for the standard frames (V2020) and spherocylinder bifocal lenses (V2203) provided
March 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital facility visit provided on November 17, 2020.
You asked the Plan to waive the copayment for an outpatient hospital facility visit. You say that you disagree with the facility charges just because of where your doctor's office is located. 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 hospital outpatient facilities and ambulatory surgical centers.
You have been asked to pay the allowed amount of $113.53, which is less than the $150 copayment for an outpatient hospital facility visit. An outpatient hospital facility visit 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 outpatient hospital facility visit provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with the Sanexas device provided on October 1, 2020.
You asked the Plan to pay for the injections and Sanexas treatment. You say that this is a medically necessary treatment which is effective for the enrollee's condition. The Plan denied your request. The Plan says there is not sufficient evidence in the medical literature to support this treatment.
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 pay for the injections and Sanexas treatment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the literature and scientific evidence supporting the use of electrostimulation/electromagnetic stimulation alone for neuropathies or peripheral neuropathies caused by underlying systemic diseases is insufficient to warrant coverage. These procedures are considered investigational and are not eligible for coverage for the treatment of neuropathies or peripheral neuropathies caused by underlying systemic diseases. The clinical value and effectiveness of the FDA Nutria-Pharmaceutical blend in the setting of chronic pain and paresthesia have not been demonstrated in the peer reviewed literature. The review has determined that the items/services at issue in this case are not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections and Sanexas treatment have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with the Sanexas device provided on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 10, 2020 by an out of network (OON) provider.

You asked the Plan to pay for an office visit. You say that these check-up appointments are very important. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider. The Plan says that these services were not rendered in a participating facility.

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 an office visit provided on December 10, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 22, 2019.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that the laboratory services are not supported in the medical record. Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral periapical x-ray image (D0220) provided on February 4, 2021.
You asked the Plan to pay for the intraoral x-ray. You say that you did not receive information from the Plan regarding any changes in your coverage, and you thought these services would be covered because they were covered last year. The Plan denied your request. The Plan says they have agreed to pay for the periodic oral exam and the cleaning; however, intraoral x-rays are not covered by your dental 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 pay for the intraoral periapical x-ray image (D0220) provided on February 4, 2021.
Your complaint about not receiving Plan coverage documents for 2021 is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and bone replacement graft (D7953) provided October 28, 2020.
You asked the Plan to pay for the guided tissue regeneration and bone replacement graft. You say that you feel this should be covered as a medical procedure and processed as surgery. The Plan denied your request. The Plan says this dental service is not covered under your Plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and bone replacement graft (D7953) provided October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the interrogation device evaluation(s) services provided on
October 31, 2020 to November 16, 2020.
You asked the Plan to pay for the interrogation device evaluation(s) services. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as
billed.
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, the CPT Code Manual definition of code 93294 is interrogation device evaluation(s) (remote), up
to 90 days; single, dual, or multiple lead pacemaker system, or leadless pacemaker system with interim
analysis, review(s) and report(s) by a physician or other qualified health care professional.
We find that CPT code 93294 is not supported in the medical record. Specifically, this code has a professional component/technical component of 2. A professional component/technical component indicator of 2 means a professional component only code. A professional component only code cannot be billed with modifier 26. Based on this information, we decided that Medicare rules for coverage of the interrogation device evaluation(s) services have not been met. Therefore, we decided that the Plan does not have to pay for the interrogation device evaluation(s) services provided on October 31, 2020 to November 16, 2020.
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 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 you were admitted with chronic obstructive pulmonary disease exacerbation and respiratory failure. The record indicates that you will require your currently used Trilogy ventilator at home. At the time of the request, you continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (93306).

You asked the Plan to pre-approve the transthoracic echocardiogram. You say that the transthoracic echocardiogram is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that transthoracic echocardiograms are covered when 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 transthoracic echocardiogram. Our reviewer says that the requested procedure is not medically necessary. Our physician reviewer found the enrollee has hypertension and is asymptomatic from a cardiac standpoint. The provided medical records do not support the medical necessity or reasonableness of the requested service.

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 transthoracic echocardiogram have not been met. Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiogram (93306).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for other procedure on skin of arms, legs, and front body (00400) provided on July 20, 2020.
You asked the Plan to pay for the anesthesia. You say that the treatment provided was not due to the enrollee's hospice diagnosis. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on July 3, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the anesthesia for other procedure on skin of arms, legs, and front body (00400) provided on July 20, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level (CPT code 64483), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan denied your request. The Plan says epidural steroid injections are allowed for a limit of no more than three (3) injections in the last six (6) months and no more than 6 injections in the last twelve (12) months. 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 service have not been met. An additional epidural steroid injection, lumbar transforaminal injection, exceeds the frequency limits allowed by Medicare of 3 injections in the last 6 months. Therefore, we decided that the Plan does not have to pre-approve injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level (CPT code 64483), for the enrollee.