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

We decided that the Plan does not have to pay for the nursing facility services rendered on June 16, 2020.
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.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 nursing facility services rendered on June 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a continuous glucose monitor.
You asked the Plan to preapprove the continuous glucose monitor. You say that the continuous monitoring is
necessary. The Plan denied your request. The Plan says you do not meet the Medicare coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not having a
qualified diagnosis, using insulin with at least three daily injections, and require frequent self-adjustment of
insulin dosage based on the blood glucose testing results.
Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to preapprove a continuous glucose monitor.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cardiac device monitoring services (93280) provided January 12, 2021.

You asked the Plan to waive the copayment for the diagnostic services. You say that you are requesting reconsideration about the double copay charged to you. The pacemaker test is not covered and the provider early billed you $100. You had a $65 copay, a $35 office visit copay and $30 for the test. 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 $30 copayment for Medicare covered non-radiological diagnostic services.

You have been asked to pay $30 copayment for the diagnostic services. The diagnostic service falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for cardiac device monitoring services (93280) provided January 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer.
You asked the Plan to pre-approve a Superion interspinous spacer. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 a Superion interspinous spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the superion spacer remains experimental. More research is needed to show safety and efficacy of the spacer.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Superion interspinous spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion interspinous spacer.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport provided on January 8, 2021.

You asked the Plan to pay for the ambulance service, basic life support, emergency transport. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 

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 ambulance service, basic life support, emergency transport. Our reviewer says that the ambulance service, basic life support, emergency transport was not medically necessary. Our physician reviewer found that the enrollee is a 74-year-old female with left foot pain after hitting it on the side of her bed who was transported via ambulance. She was found to be alert, oriented, Glasgow 15, normal lung and skin exam, able to walk with a limp and with normal and stable vitals. The presenting symptoms did not meet prudent layperson criteria for emergency care. A stretcher van or wheelchair van would have been sufficient and were not contraindicated for this enrollee's condition. The documentation does not support that the enrollee needed experienced staff or special equipment during transport. The ambulance services will be considered not medically necessary for the enrollee based on the documentation provided.

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 ambulance service, basic life support, emergency transport. have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429, A0425) provided on January 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a limited oral evaluation (D0140), and endodontic therapy (D3330) provided from February 17, 2021, through February 19, 2021.

You asked the Plan to pay an additional amount for a limited oral evaluation, and endodontic therapy. You say that this out-of-network provider was recommended by your general dentist and you did not want to see the in-network providers. The Plan denied your request. The Plan says the benefit maximum had already 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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, and endodontic therapy have not been met. Specifically, the record shows that you had exhausted your dental benefit maximum.

Therefore, we decided that the Plan does not have to pay an additional amount for a limited oral evaluation (D0140), and endodontic therapy (D3330) provided from February 17, 2021, through February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refractions (92015) or waive the deductible for the outpatient visit (99204) received January 7, 2021.

You asked the Plan to pay for the refractions and outpatient visit. You say that you would like the Plan to pay for these services. The Plan denied your request. The Plan says there is no coverage for eye refractions. Your cost share for the outpatient visit processed in your deductible.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The rules also say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $160 deductible for covered medical services. 

The eye refractions you asked the Plan to pay for are considered routine vision services or eyewear and not covered. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $160 deductible for covered medical services. This cost sharing is a contractual obligation that had not been met at the time the outpatient visit was received on January 7, 2021. Therefore, we decided that the Plan does not have to pay for the eye refractions (92015) or waive the deductible for the outpatient visit (99204) received January 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for biopsy, bone, open; deep (eg, humeral shaft, ischium, femoral shaft) (CPT code 20245-AS) provided to the enrollee on February 18, 2021, by an assistant surgeon.

You asked the Plan to pay for the services. You say that the primary surgeon requested services as an assistant surgeon was medically necessary throughout the surgery. The Plan denied your request. The Plan says the services of an assistant surgeon, co-surgeon, or surgical team are not covered for this procedure.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 20245. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the services have not been met.

Therefore, we decided that the Plan does not have to pay for biopsy, bone, open; deep (eg, humeral shaft, ischium, femoral shaft) (CPT code 20245-AS) provided to the enrollee on February 18, 2021, by an assistant surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services you received on March 13, 2020.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says out-of-network services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. The services in question were provided to you by an out-of-network dentist. The Plan contract clearly states that you must pay 100% of the cost for out-of-network dental services. Therefore, we decided that the Plan does not have to pay for the dental services you received on March 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device (L8702).
You asked the Plan to pre-approve a MyoPro Motion G Orthotic device. You say that the enrollee has failed other treatments. The Plan denied your request. The Plan says this would exceed the enrollee's needs.
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 a MyoPro Motion G Orthotic device. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the use of robotic therapy for upper and lower extremity stroke rehabilitation is investigational in nature and there is no long-term outcome data for use of this 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 a MyoPro Motion G Orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a filling (D2330) provided on March 4, 2021.
You asked the Plan to pay for a filling. You say that the service was necessary. The Plan denied your request. The Plan says the service 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 pay for a filling (D2330) provided on March 4, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for SNF services provided from February 27, 2020, through
March 1, 2020.
You asked the Plan to pay for SNF care. You say that you believe you have paid the SNF the correct amount due. The Plan denied your request. The Plan says that there is a $0 copayment for the first 21 days and $100 per day copayment for days 21-100 days in a Skilled Nursing Facility. You pay this amount until you reach the out-of-pocket maximum.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before February 26, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pay for SNF services provided from February 27, 2020, through March 1, 2020.
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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after July 25, 2021.
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that that the services you now require are called custodial care.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before July 25, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after July 25, 2021.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a filling (D2392) provided on March 12, 2021.
You asked the Plan to pay for a filling. You say that you were not aware that the provider was out-of-network. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network provider.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a filling have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these 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 a filling (D2392) provided on March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on September 29, 2020 by an out of network (OON) provider.

You asked the Plan to pay for genetic testing. 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 the member's primary care physician. 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 genetic testing provided on September 29, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 27, 2021.

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 had network providers available who could have provided 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 services provided by an out-of-network provider on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the test for balance and posture (92548) provided on February 18, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the test for balance and posture. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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 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 test for balance and posture (92548) provided on February 18, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the abdominal ultrasound (76700) provided on March 30, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $100 copay for diagnostic procedures and tests, including ultrasounds, at all locations of service.

You have been asked to pay a $100 copayment for the ultrasound provided. 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 abdominal ultrasound (76700) provided on March 30, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on August 6, 2020.

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 had network providers available who could have provided 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 services provided by an out-of-network provider on August 6, 2020.