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

We decided that the Plan does not have to pay for the services rendered on October 22, 2019.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 are not covered when performed by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The file shows that the provider submitted a claim for procedure codes J3490 (unclassified drugs), 97112 (neuromuscular reeducation), 97016 (vasopneumatic therapy), and 96372 (therapeutic injection). Therefore, we decided that the Plan does not have to pay for the services rendered on October 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. You say that the enrollee is unable to use the stairs independently. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).
You asked the Plan to pre-approve the core buildup. You say that the buildup is necessary due to distal lingual fracture with decay, and more than half of this tooth is gone. You also say that the buildup is necessary to prevent loss of the tooth. The Plan denied your request. The Plan says Medicare does not cover this service and therefore this service is not covered by the Plan.
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 a core buildup, including any pins when required (D2950).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Inflectra.
You asked the Plan to pre-approve Inflectra. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet coverage criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Inflectra. Our reviewer says that the provided medical records do not support that the Inflectra is medically reasonable and necessary for the member. The member has not met the prior authorization criteria required by the Plan (Prescribed by or given in consultation with a dermatologist and has a documented diagnosis of chronic severe plaque psoriasis, i.e. body surface area at least 5% or involvement affecting the hands, feet, or genital area). Our physician reviewer found the provided medical records do not support that the Inflectra is safe and effective for the member. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Inflectra have not been met. Therefore, we decided that the Plan does not have to pre-approve Inflectra.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on January 27, 2020. You asked the Plan to waive the copayment for the specialist office visits. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 per specialist visit. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office 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 the specialist office visit provided on January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ostomy supplies provided on January
15, 2020.
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that the cost is a hardship. The
Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for prosthetic devices and medical supplies.
You have been asked to pay $68.32 which is 20% of the allowed amount for the ostomy supplies. The allowed
amount is $341.60. ($341.60 x 20% = $68.32). The ostomy supplies fall within the "Prosthetic devices and
related 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 the ostomy supplies
provided on January 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on January 29, 2020.
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says that 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
drug test. 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 a drug test provided on January 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray coded 71045 provided on February 7, 2020.
You asked the Plan to pay for the x-ray. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the services billed are a duplicate claim.
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 CPT code 71045 is not supported in the medical record. Specifically, this code is a duplicate claim
to a claim that has been previously processed. Based on this information, we decided that Medicare rules for
coverage of the x-ray have not been met.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transport provided July 25,
2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be
waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 $225
copayment for ambulance services.
You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport 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 an
ambulance transport provided July 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 2, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on September 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services could have been provided with 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 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 skilled nursing services provided on September 30, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on June 12, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were available in-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 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 for the medical services provided to the enrollee by an out-of-network provider on June 12, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of physical therapy services
You asked the Plan to pre-approve the physical therapy services. You say that you would like reconsideration because without the continuation of supervised physical therapy, the member is at significant risk of falling and incurring bodily injury. The Plan denied your request. The Plan says the member has not improved significantly and detail is lacking in the skills that require further treatment of the member's condition by a physical therapist.
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 the physical therapy services. 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 the requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the member's current condition or to prevent or slow further deterioration. 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 physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of physical therapy services
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to provide coverage for the plastic lenses. We decided that the Plan does not have to provide coverage for progressive lenses.
You asked the Plan to provide coverage for the glasses. You say that you would like reconsideration because this should be a covered benefit. The Plan says that these supplies are not covered benefits.
We decided that the Plan has to provide coverage for the plastic lenses. The file shows that you have a medical indication for which Medicare will cover the plastic lenses. Therefore, we decided that the Plan has to provide coverage for the glasses.
We also decided that the Plan does not have to provide coverage for the progressive lenses.
The Plan follows Medicare rules. The rule says that Scratch resistant coating (V2760), mirror coating (V2761), polarization (V2762), deluxe lens feature (V2702) and progressive lenses (V2781) will be denied as noncovered. The file does not show that you have a medical indication for which Medicare will cover progressive lenses. Therefore, we decided that the Plan does not have to provide coverage for plastic lenses.
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.
Your complaint about being given incorrect information regarding your vision benefit 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 periodic oral evaluation, prophylaxis, bitewings, and
resin-based composite provided on December 2, 2019 and December 11, 2019 by you, an OON provider.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, bitewings, and resin-based composite.
You say that you and the enrollee called prior to the services being rendered and you were both told that you
were an in-network provider. You also say that neither your office nor the enrollee were notified that you were
OON with the enrollee's plan. The Plan denied your request. The Plan says you are an OON provider with the
enrollee's plan. The Plan also says that no benefits are available for procedures that are performed by OON
providers or outside of the providers contracted period.
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
covered when received by an OON provider. The Plan confirmed that their call records show that on December
2, 2019 your office was informed that you were OON with the enrollee's plan. Therefore, we decided that the
Plan does not have to pay for the periodic oral evaluation, prophylaxis, bitewings, and resin-based composite
provided on December 2, 2019 and December 11, 2019 by you, an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. The Plan denied your request. The Plan says the service could be provided by a participating 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 chiropractic services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve chiropractic services to be provided by an out of network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702). You asked the Plan to pre-approve the MyoPro myoelectric orthosis. You say that you are requesting the plan to approve the appropriate and medically necessary car to allow the enrollee to succeed in return of function of his impaired left arm. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MyoPro myoelectric orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight wheelchair.
You asked the Plan to pre-approve a lightweight wheelchair. You say that you need a lightweight wheelchair to leave home to get to doctor appointments etc. The Plan denied your request. The Plan says the record shows that your mobility needs within your home can be sufficiently and safely resolved by use of your four-wheeled walker with seat.
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 wheelchairs for use only outside the home. The wheelchair evaluation shows you are an independent household ambulator. Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on October 3, 2019.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 procedure code 38999 is not supported.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 38999 is unlisted procedure, hemic or lymphatic system.We find that CPT code 38999 is not supported in the medical record. Specifically, the operative report does not contain documentation of an unlisted procedure of the hemic of lymphatic system. 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 pay for the surgical services rendered on October 3, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 77081) provided to the enrollee on January 23, 2020.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the enrollee had multiple exams on the same date of service.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 77081 is "Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites."We find that CPT code is not supported in the medical record. Specifically, this code is a column II procedure to the column I procedure already billed on this claim -CPT 77080. This code cannot be billed separately. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for radiology services (CPT 77081) provided to the enrollee on January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on April 22, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized. 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 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 for the medical services provided to the enrollee by an out-of-network provider on April 22, 2019.