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

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, full mouth debridement,
preventive procedure, and comprehensive oral evaluation provided on October 21, 2020.

You asked the Plan to pay for the first intraoral periapical x-ray, full mouth debridement, preventive procedure,
and comprehensive oral evaluation. You say that you would like these services to be covered by the Plan. The
Plan denied your request. The Plan says the first intraoral periapical x-ray, full mouth debridement, and
preventive procedure are not covered. The Plan also says that your benefit maximum for the comprehensive
oral evaluation has been met.

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 first intraoral periapical x-ray, full
mouth debridement, and preventive procedure are not among those covered under this benefit. The Plan
contract also says that comprehensive oral evaluations are limited to once every 36 months. The record shows
that you received a comprehensive oral evaluation on March 13, 2018, and your comprehensive oral evaluation
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral
periapical x-ray, full mouth debridement, preventive procedure, and comprehensive oral evaluation provided on
October 21, 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 for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

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. The enrollee 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 he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the anesthesia services (00731).

You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration because a modifier is not necessary for this payable code. The Plan denied your request. The Plan says that this claim was billed with an inappropriate modifier.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 00731 is supported in the record. Specifically, this service is being billed by a MD. The QK modifier is appropriate for physician services. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have been met. Therefore, we decided that the Plan has to pay for the anesthesia services (00731).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for duplex scan of lower extremity arteries or
arterial bypass grafts (93925) duplex scan of extremity veins including responses to compression and other
maneuvers (93970) limited bilateral noninvasive physiologic studies of upper or lower extremity arteries
(93922).

You asked the Plan to waive the copayment for the diagnostic services. You say that based on the wording of
the EOB which states "do not bill the member" you should not be held responsible for any copay. The Plan
denied your request. The Plan says the claim was processed and the correct copayment was applied per the
Evidence of Coverage.

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 $160
copayment for each radiological diagnostic service, not including x-rays, performed in a physician's office or
free-standing facility.

You have been asked to pay $365 ($160 + $61.75 + $143.31 = $365.06) for the diagnostic services. For CPT
code 93922, the allowed amount was less than the copay amount, therefore the allowed amount of $61.75 was
applied as your responsibility. For CPT code 93970, the allowed amount was less than the copay amount,
therefore the allowed amount of $143.31 was applied as your responsibility. The diagnostic services fall 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 copayment for duplex scan of lower extremity
arteries or arterial bypass grafts (93925) duplex scan of extremity veins including responses to compression and
other maneuvers (93970) limited bilateral noninvasive physiologic studies of upper or lower extremity arteries
(93922).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a sleep study for the enrollee.

You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your request. The Plan says that a home sleep study may be an option for further evaluation of concerns.

The Plan must follow Medicare rules. Medicare rules say that services are covered 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 study. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found polysomnography with PAP titration is considered medically necessary for the enrollee. The enrollee was diagnosed with severe OSA in 2014, and was successfully treated with CPAP at pressure of 8. Recent downloads show high residual AHI, indicating CPAP is not entirely effective in correcting the sleep disordered breathing. There has been no substantial weight change (less than 3%) since 2014. Usage has been excellent. A new PAP titration is needed to adequately treat the OSA.

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 study have been met. Therefore, we decided that the Plan has to pre-approve a sleep study for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve physician services. You say that you would like to keep all your doctors in one location. You say that this is easier for you. The Plan denied your request. The Plan says there are in-network providers available for these services.

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-approve physician services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), resin-based composite of two surfaces (D2392), and resin-based composite of three surfaces (D2393).

You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and resin-based composites. You say that prior to receiving these services you were advised that you were covered. You also say that you were told that you would only owe $190 for these services and the rest would be covered by the Plan. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan. The Plan also says that the problem focused limited oral evaluation is not a covered benefit and was paid in error, but the Plan is not recouping the amount paid for this service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

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 problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), resin-based composite of two surfaces (D2392), and resin-based composite of three surfaces (D2393).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services.

You asked the Plan to pay for these services. You say that the services were needed. The Plan denied your
request. The Plan says the provider opted out of Medicare.

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 for the
anesthesia services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 2 segmental pneumatic appliances (E0667 x 2).

You asked the Plan to pre-approve a pneumatic compression device and 2 segmental pneumatic appliances. You say that the enrollee experienced exacerbated symptoms when using a basic device (E0651) and was unable to tolerate a single treatment, let alone 4 weeks of treatment. The Plan denied your request. The Plan says rules for pre-approval have not been met.

The Plan does not have to pre-approve a pneumatic compression device (E0652).

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).

The Plan does not have to pre-approve 2 segmental pneumatic appliances (E0667 x 2).

PCD related accessories, such as E0667, are eligible for payment only when the appropriate, related base PCDs meets the applicable coverage criteria for that type of PCD. In this case, the requested PCD (E0652) does not meet the applicable coverage criteria. Therefore, we decided that the Plan does not have to pre-approve 2 segmental pneumatic appliances (E0667 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a negative pressure wound therapy device and supplies.

You asked the Plan to pay for the negative pressure wound therapy device and supplies. You say that the
documentation provided supports the items in dispute. You say that the Plan has previously paid for the
supplies that go with the wound pump. The Plan denied your request. The Plan says the criteria for coverage
have not been met and the requested items are not considered medically reasonable or necessary.

The Plan follows Medicare rules. Medicare rules say that negative pressure wound therapy devices and
supplies are covered for certain medical 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 pay for the negative pressure wound therapy device
and supplies. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found
the enrollee has a medical history of DVT, COPD, hypertension, chronic kidney disease, and bladder cancer.
He suffered an injury to his left leg in a fall. The enrollee developed an open wound with cellulitis and eschar
over the top of a large hematoma. The enrollee was hospitalized and debridement was
performed. The enrollee received subsequent care in a skilled nursing facility. Our physician
reviewer found that the documentation is insufficient in regard to the enrollee being treated in a wound therapy
program.

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 negative pressure wound therapy device and supplies have not been met.
Therefore, we decided that the Plan does not have to pay for a negative pressure wound therapy device and
supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz injection (J7321).

You asked the Plan to pre-approve Supartz. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says step therapy criteria has not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Supartz. Our reviewer says that step therapy criteria has not been met. Our physician reviewer found the enrollee is a 71-year-old male with pain related to osteoarthritis of the left knee, diagnosis confirmed with imaging studies. Based on the medical records provided the patient has not tried and failed the required drugs Orthovisc and Monovisc. In addition, there is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the patient.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz injection (J7321).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance services (A0431, A0436).

You asked the Plan to pay for the air ambulance services. You say that the service provided was medically necessary. The Plan denied your request. The Plan says the service was not medically necessary.

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.

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 air ambulance services. Our reviewer says that the service provided was not medically reasonable and necessary. Our physician reviewer found the patient is a 65-year-old female with fracture of neck of left femur. Air ambulance was requested. Emergency responders found the patient to be hemodynamically stable and not requiring emergent services. There was no documented contraindication to ground ambulance transportation in this case.

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 air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance services (A0431, A0436).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for these services. You say that there was no time to submit prior authorization. The Plan denied 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 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 medical services provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a CPAP device.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the compliance report shows usage less than 70% of nights.

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 recent device downloads show that the usage does not meet Medicare benefit criteria of at least four hours per night for at least 70% of the nights. Your use of the device is insufficient to provide clinical benefit. The records do not show a recent office visit to address the compliance issues.

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 continued use of a CPAP device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the hearing aids rendered by the out of network (OON) provider.

You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids 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 had network providers available who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aids rendered by the out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out of network (OON) provider.

You asked the Plan to pay for psychotherapy. You say that these services were provided in good faith. The Plan denied your request. The Plan says authorization was not obtained by the physician or by the skilled nursing 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 psychotherapy provided by an out of network (OON) provider.