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

We decided that the Plan does not have to pay for the office visit coded 99215 provided on January 6, 2021.
You asked the Plan to pay for the office visit. 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 CPT code 99215 is not supported in the medical record. Specifically, this code was billed with a manifestation code. Manifestation codes cannot be billed as first listed diagnosis on claim. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99215 provided on January 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria have not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 48 one-way transportation trips when each one-way trip does not exceed 50 miles. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vascular surgery consultation to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a vascular surgery consultation. You say that this provider can perform the surgery for the enrollee. The Plan denied your request. The Plan says that there are in-network cardiovascular surgeon(s) within 10 miles from the enrollee's location that can provide this service.
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 a vascular surgery consultation 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 an additional amount for contact lenses (V2599 x4), and anti-reflective coating (V2750 x2) received on October 21, 2020. You asked the Plan to pay an additional amount for contact lenses, and anti-reflective coating. You say that you want the Plan to pay an additional amount for the items. The Plan denied your request. The Plan says The Plan says the benefits were applied correctly. The benefit maximum allowance had already been met.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to a $100 allowance, then you are responsible for paying the difference. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of contact lens, and anti-reflective coating have not been met. Specifically, the record shows that you had exhausted your eyewear benefit maximum of $100. Therefore, we decided that the Plan does not have to pay an additional amount for contact lenses (V2599 x4), and anti-reflective coating (V2750 x2) received on October 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Bio Electro-Magnetic Regulation (BEMER) 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 this is not considered a standard of care for your condition.
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 device is not considered medically reasonable and necessary in this case. Our physician reviewer
found Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis
or treatment of illness or injury or to improve the functioning of a malformed body member. This device is not
proven to be effective for your condition and is also not considered the standard of care.
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 the Bio Electro-Magnetic Regulation (BEMER) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner chair.
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your request. The Plan says this does not serve a primarily medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a recliner chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture and complete mandibular
denture to be rendered by an OON provider.
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say
that you would like these dentures to be approved for coverage. The Plan denied your request. The Plan says
services rendered by an OON or non-contracted provider are not covered. The Plan also says that there are
multiple in-network providers in your area who can render these services.
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 they are received OON. Therefore, we decided that the Plan does not have to pre-approve a
complete maxillary denture and complete mandibular denture to be rendered by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided October 14, 2020.
You asked the Plan to pay for the inpatient services. You say that you do not agree with the denial and you
would like to appeal. The Plan denied your request. The Plan says any necessary medical services would have
to be processed under your no fault, automobile insurance, as primary.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan is the secondary
insurer. As the secondary insurer, the Plan cannot be held responsible for the inpatient services until the
primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to
pay for the inpatient hospital services provided October 14, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage and ambulance service provided on November 13, 2020.
You asked the Plan to pay for the ground mileage and ambulance service. You say that the enrollee's diagnosis is not related to hospice. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ground mileage and ambulance service provided on November 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options.
You asked the Plan to pre-approve the Group 3 PWC. You say that the enrollee needs the requested Group 3 PWC. The Plan denied your request. The Plan says the enrollee does not have a mobility deficit caused by a neurological condition.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: a neurological condition; myopathy; or, a congenital skeletal deformity. The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Although there is a history of stroke, the records show that the main
cause of the mobility deficit is the amputation of the lower limb. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and the non-emergency transportation (A0428) provided on November 16, 2020.
You asked the Plan to pay for the transportation services. You say that the enrollee's diagnosis is not related to hospice. You say that the services provided were not related to hospice care. You also say that the services were provided to the enrollee in good faith. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and the non-emergency transportation (A0428) provided on November 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous surgery (D4261) for all 4 quadrants.
You asked the Plan to pre-approve the dental services. You say that according to your understanding of the optional supplemental dental rider, these services should be covered. The Plan denied your request. The Plan says osseous surgery is not listed as covered. The Plan also says that any service not listed is 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve osseous surgery (D4261) for all 4 quadrants.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from October 9, 2020, to November 23, 2020.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you were told that the services were not necessary. 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 $40 copayment for outpatient rehabilitation services. You received outpatient rehabilitation services from October 9, 2020, to November 23, 2020, for a total of 13 visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40
(copayment) x 13 (outpatient rehabilitation services) = $520. You have been asked to pay the total copayment amount of $520 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 copayments for outpatient rehabilitation services provided from October 9, 2020, to November 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cooled facet nerve neurolysis for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that the method to be used is thermal and non-pulsed.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found cooled radiofrequency ablation is not a Medicare-accepted method. Only the traditional non-pulsed thermal method is deemed acceptable. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve cooled facet nerve neurolysis for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical massage therapy.
You asked the Plan to pre-approve the massage therapy. You say that you have lumbar disk disease for which your neurologist has prescribed medical massage therapy. You are receiving physical therapy as well and doing home exercises, but your condition continues to limit your mobility. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Although therapeutic massage may be covered when done by a physical/occupational therapist as part of a plan of care, the services of a massage therapist cannot be covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve medical massage therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 11, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a video visit after your chemo treatment and you disagree with the charges. 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 $30 copayment for specialist visits. You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services including 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 February 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on January 20, 2021.
You asked the Plan to pay for the periodontal maintenance. You say that you need this service to be covered. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify your benefits.
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 periodontal maintenance provided on January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided December 3, 2020 and the deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15 minute increment (D9223), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided January 20, 2021.
You asked the Plan to pay for the panoramic x-rays, dental consultation, sedation/anesthesia, and tooth extraction. You say that you paid extra for a dental plan and expected the services to be covered. The Plan
denied your request. The Plan says you have reached your maximum limit for x-rays for the year 2020 and the remaining services are not covered under your dental benefits.
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. The Plan covers the panoramic x-rays once a year. The Plan does not list dental consultations, sedation/anesthesia, or tooth extractions as covered services.
We looked at the file and Medicare rules. The Plan provided documentation showing that bitewing-x-rays were previously covered on March 12, 2020. Based on this information, we decided that the Plan's frequency limit for x-rays in the year 2020 has been met and the Plan is not required to cover the x-rays at issue. Though the Plan offers a dental benefit in excess of Medicare coverage, the remaining 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 panoramic radiographic image (D0330) and consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided December 3, 2020 and the deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15 minute increment (D9223), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided January 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the member's life and health are in danger without the requested services. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The patient was admitted for a stroke. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.