Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the surgical services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says utilization of network providers is required when possible and available.
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 the medical services provided on October 22, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on January 11, 2020.You asked the Plan to waive the copayment forlaboratory services. You say that you did not receive the results and 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 $15 copayment for laboratory tests.You have been asked to pay a $15 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic service 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 forlaboratory services provided on January 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete maxillary and complete mandible dentures (D5110 and D5120).You asked the Plan to pre-approve complete maxillary and complete mandible dentures (D5110 and D5120). You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the request for D5110 dentures and D5120 dentures are denied because the services are limited to one every 60 months according to the Dental Customer Handbook. The Plan says you had D5211 and D5212 both on November 13, 2019 and would not be eligible again until November 2024.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 dentures (D5110 and D5120) are not among those covered under this benefit at this time. Your contract with the Plan clearly says these dentures are limited to one every 60 months. The file shows you received completes dentures (D5211 and D5212) on November 13, 2019 and you would not be eligible again until November 2024.Therefore, we decided that the Plan does not have to pre-approve complete maxillary and complete mandible dentures (D5110 and D5120).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided by on November 26, 2019.
You asked the Plan to pay for self-administered drugs. You say that this bill should be covered by the Plan. The Plan denied your request. The Plan says claims for self-administered drugs must be submitted to your Medicare Part D carrier.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided on November 26, 2019.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 additional physical therapy (PT) visits.
You asked the Plan to pre-approve 3 additional PT visits. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 3 additional PT visits. 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 for debility, PT is generally accepted as specific and effective therapy. Goals include reducing pain, restoring function, and educating regarding a home exercise program (HEP) prior to transition towards a home program. In this case, there is no documented re-evaluation and/or re-certification following an initial course of in-home therapy. Therefore, this request is deemed not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 additional physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from October 30, 2019 to December 30, 2019. You asked the Plan to waive the coinsurance for DME and related supplies. You say that you cannot afford 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 20% coinsurance for DME and related supplies. You received DME and related supplies on October 30, 2019. The total allowed amount is $297.78 and 20% of that is $59.56. You received DME and related supplies on November 30, 2019. The total allowed amount is $297.78 and 20% of that is $59.56. You received DME and related supplies on December 30, 2019. The total allowed amount is $123.76 and 20% of that is $24.75. The total amount you owe is: $143.87. You have been asked to pay the total coinsurance amount of $143.87 for DME and related supplies. DME and related supplies fall within the DME 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 DME and related supplies provided from October 30, 2019 to December 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on September 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also 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 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 lab work provided on September 6, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous glucose monitor supplies (K0553 and K0554) provided on January 8, 2020.
You asked the Plan to pay for the continuous glucose monitor supplies. You say that you would like reconsideration as this order follows Medicare guidelines. The Plan denied your request. The Plan says the record does not indicate that the provider discussed the need for the billed supply code and the Proof of Delivery is not itemized to indicate the specific supplies.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for continuous glucose monitor supplies (K0553 and K0554) provided on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on November 19, 2019.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says that you have met your dental limits for 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. The Plan covers $900 every year for non-Medicare covered preventive dental services and non-Medicare covered comprehensive dental services. We looked at the file and Medicare rules. The file shows that the plan has approved the maximum yearly benefit of $900 for the requested services. There is no provision in the contract which would require the plan to approve more than this amount. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for the dental services provided on November 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated (L8702), for the enrollee.
You asked the Plan to pre-approve the device. You say that the documentation indicates services are not necessary for treatment of the enrollee's condition. The Plan denied your request. The Plan says the documentation indicates services are not necessary for treatment of the enrollee's condition.
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 physician reviewer found the L8702 - Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated is not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member per the Social Security Act, Section 1862(a)1(A).The MyoPro Orthosis is not the most appropriate available supply or level of service for the patient considering potential benefits to the patient. It is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes for hemiparesis after stroke. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this patient, improve his hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase the patient's participation in bimanual activities. Additional controlled studies of the MyoPro requested device for upper extremity paralysis after stroke are needed with larger patient groups, consistent improvements of relevant outcome functional measures, and long term follow up. 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 powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated (L8702), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a foot insert (L3000) provided on November 11, 2019.
You asked the Plan to pay for a foot insert. You say that this should be covered because you purchased it at your doctors office. The Plan denied your request. The Plan says this was not purchased from a Medicare-approved supplier.
The Plan must follow Medicare rules. Medicare rules say that in order to be reimbursed for the DME supplies that they sell, providers must separately enroll in Medicare as a supplier of DME. We looked at the file and Medicare rules. The provider you purchased this item from is not enrolled in Medicare as a supplier of DME. Based on this information, we decided that Medicare rules for coverage of a foot insert have not been met. Therefore, we decided that the Plan does not have to pay for a foot insert (L3000) provided on November 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz Injections (J7321).You asked the Plan to pre-approve Supartz. You say that Supartz is medically necessary.The Plan denied your request. The Plan says a trial of Synvisc or Euflexxa is required before alternatives can be considered.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 coverage criteria is not met. Our physician reviewer found the enrollee has not had a documented trial of the plan preferred drugs.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 Injections (J7321)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on June 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that the member is in a skilled nursing facility; therefore, the doctor is not responsible to get authorization. The Plan denied your request. The Plan says the referring facility is out-of-network. The Plan says that no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 June 24, 2019 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 contact lens fitting provided on September 23, 2019.
You asked the Plan to pay for the fitting. The Plan denied your request. The Plan says that your eyewear
benefit was exhausted on this date of service.
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 up to a maximum of $150 once every 24 months for eyewear.
We looked at the file and the Plan's rules. The file shows that the plan has approved the maximum 24 month
benefit of $150 for the requested services. There is no provision in the contract which would require the plan to
approve more than this amount. Therefore, we decided that the Plan does not have to pay for the contact lens
fitting provided on September 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of tunneled centrally inserted central venous access device (36561) provided on March 20, 2019.You asked the Plan to pay for the insertion of tunneled centrally inserted central venous access device. You say that you would like reconsideration because this is not a duplicate bill.The Plan denied your request. The Plan says there is no additional documentation supporting an additional procedure which was billed and remained denied.The Plan must follow Medicare rules. Medicare rules say that or Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insertion of tunneled centrally inserted central venous access device have not been met. Specifically, the record indicates that one unit of CPT code 36561 has already been approved and paid by the Plan. There is no additional documentation to support that an additional service was rendered.Therefore, we decided that the Plan does not have to pay for the insertion of tunneled centrally inserted central venous access device (36561) provided on March 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for tissue transfer (14301) provided on September 11, 2019.
You asked the Plan to pay for tissue transfer. You say that this should be reviewed for payment. The Plan denied your request. The Plan says the measurements of the adjacent tissue transfer or rearrangement are not documented in the records.
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 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. We find that CPT code 14301 is not supported in the medical record. Specifically, this code is for 30.1 sq cm to 60.0 sq cm. As there is no measurement documented in the submitted records, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of tissue transfer have not been met. Therefore, we decided that the Plan does not have to pay for tissue transfer (14301) provided on September 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay in full forlens enhancements (V2750, V2755, V2781) provided December 12, 2019.You asked the Plan to pay in full forthe lensenhancements. You say that the lens enhancements should be covered.The Plan denied your request. The Plan says the correct cost sharing has been applied to the lens enhancements at issue.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 but with a $150-$175 copayment for Custom Progressive Lenses and a 20-25% discount for other lens enhancements.We looked at the file and the Plan's rules. The correct cost sharing was applied based on the plan contract. Therefore, we decided that the Plan does not have to pay in full forlens enhancements (V2750, V2755, V2781) provided December 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the knee scooter purchased on November 13, 2019.You asked the Plan to pay the rental charge and reimburse you for the knee scooter. You say that you could not wait for a knee scooter so you bought one. The Plan denied your request. The Plan says the provider is not eligible to participate in Medicare and therefore the claim cannot be paid.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The knee scooter was provided by a provider not certified by Medicare. Based on this information, we decided that Medicare rules for coverage of the knee scooter have not been met.Therefore, we decided that the Plan does not have to reimburse you for the knee scooter purchased on November 13, 2019.