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

We decided that the Plan does not have to pay for dental services (D7210, D1999) provided by an out-of-network (OON) provider.
You asked the Plan to pay for OON dental services. You say that you requested a list of in-network providers and did not receive it. The Plan denied your request. The Plan says services from OON providers 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, only services provided by in-network providers are covered. Therefore, we decided that the Plan does not have to pay for dental services (D7210, D1999) provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe coronary CT angiogram (75574).You asked the Plan to pre-approvethe coronary CT angiogram. You say that you would like reconsideration because this service is medically necessary.The Plan denied your request. The Plan says this service is not indicated or medically reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the coronary CT angiogram. Our reviewer says that the member does not have symptoms or objective findings suggestive of coronary disease. The member does not have a documented chest pain syndrome or equivocal stress test results or suspected congenital anomaly. The records do not support the medical necessity for a coronary CT angiogram since there are no documented covered indications for the procedure. Our physician reviewer found guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including coronary CT scanning.  Treatment change or addition based on the results of screening with coronary CT scanning has not been shown to improve cardiac outcome incremental to that achievable by treatment based on a combination of standard risk factor profiling and basic lipid analysis.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 coronary CT angiogram have not been met.Therefore, we decided that the Plan does not have to pre-approvethe coronary CT angiogram (75574).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve.eplerenone.

You asked the Plan to pre-approve.these services. You say that you disagree with the denial.The Plan denied your request. The Plan.says self-administered drugs are not covered.

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 pre-approve.eplerenone.

Benefits for these services.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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for the emergency room (ER) services rendered.

You asked the Plan to waive the copayment for these services. You say that you do not consider the services to be outpatient treatment.The Plan denied your request. The Plan says the copayment was applied correctly.

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 copayment for Medicare-covered emergency room visits. 

Review of the file shows that you received ER services on September 2, 2020. You have been asked to pay a $100 copayment for these services. These services fall within the Medicare-covered emergency room 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 emergency room (ER) services rendered.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forelectrical stimulator supplies (A4595) provided August 20, 2020.You asked the Plan to pay forthe electrical stimulator supplies. You say that the items were medically necessary.The Plan denied your request. The Plan says the documentation does not support the items billed.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 does not contain a valid proof of delivery. The proof of delivery shows a delivery date of April 2, 2020. The billed date of service is for August 20, 2020. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay forelectrical stimulator supplies (A4595) provided August 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Purewick female external catheter and urine collection system
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit because it is not reasonable and necessary for the treatment of illness or injury.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 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 in this case, the Medicare guidelines say that this item or service is not a covered benefit because it is not reasonable and necessary for treatment of illness or injury nor is it re-usable, it is not medical in nature and it is used for comfort, hygiene and convenience. The review has determined that there is no specific medical purpose for this request to be considered medically necessary and reasonable. We looked at this physician's review, the file, and Medicare rules. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 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 the Purewick female external catheter and urine collection system.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services (97140, 97112, 97110, 97161) to be provided by an out of network provider.
You asked the Plan to pre-approve the physical therapy services. You say that the out-of-network provider is closer to your home. The Plan denied your request. The Plan says there are network providers available that can provide the services at issue.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services (97140, 97112, 97110, 97161) to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea total electric hospital bed.You asked the Planto pre-approvethe bed. You say that this is medically necessary.The Plandenied your request. The Plansaysthis not a coveredbenefit.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plandoes not haveto pre-approvea total electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627, E1399).
You asked the Plan to pre-approve the seat lift mechanism. You say that the seat mechanism is medically necessary. The Plan denied your request. The Plan says coverage rules have not been met.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. 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 seat lift mechanism. Our reviewer says that the seat lift mechanism is not medically necessary. Our physician reviewer found the patient does not have severe arthritis of the hip or a specific neuromuscular disease. The records do not clearly show that the patient is completely incapable of standing from a chair. 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 seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism (E0627, E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued tumor treatment field therapy (TTFT).
You asked the Plan to pre-approve continued tumor treatment field therapy (TTFT). You say that the requested
continuation of tumor treatment field therapy (TTFT) is medically necessary. The Plan denied your request.
The Plan says the enrollee does not meet criteria for continued tumor treatment field therapy (TTFT).
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 continued tumor treatment field therapy
(TTFT). Our reviewer says that the enrollee does not meet criteria for continued tumor treatment field therapy
(TTFT). Our physician reviewer found the enrollee is diagnosed with glioblastoma and has been receiving
TTFT from May 2020 to January 2021. Based on the documentation provided, as of September 2020, an MRI
showed progression. Therefore, the enrollee does not meet LCD criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued tumor treatment field therapy (TTFT) have not been met. Therefore,
we decided that the Plan does not have to pre-approve continued tumor treatment field therapy (TTFT).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diagnostic procedures provided on September 4, 2020.You asked the Plan to pay forthe diagnostic procedures. You say that the Plan should pay this claim.The Plan denied your request. The Plan says the procedures require a professional component modifier in POS 22.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate POScode.The Plan has a facility claim on file already reporting the TC portion of these procedures.Based on this information, we decided that Medicare rules for coverage of the diagnostic procedures have not been met.Therefore, we decided that the Plan does not have to pay forthe professional component of the diagnostic procedures provided on September 4, 2020.
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.

You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because IRF admission is medically necessary.The Plan denied your request. The Plan says your needs may be met at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.

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. Our physician reviewer found your medical status does not require intensive physician or nursing supervision in an IRF.

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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for vitamin D; 25 hydroxy, includes fraction(s), if performed (CPT Code 82306) provided on August 5, 2020.
You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied your request. The Plan says Medicare says preventative vitamin assays and metabolic function tests are not a covered benefit.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met. Medicare says preventative vitamin assays and metabolic function tests are not a covered benefit. Medicare considers vitamin assay panels (more than one vitamin assay) a screening procedure and therefore, non-covered. Similarly, assays for micronutrient testing for nutritional deficiencies that include multiple tests for vitamins, minerals, antioxidants and various metabolic functions are never necessary. Any diagnostic evaluation should be targeted at the specific vitamin deficiency, and not a general screen. Most vitamin deficiencies are nutritional in origin and may be corrected with supplemented vitamins. Therefore, we decided that the Plan does not have to pay for vitamin D; 25 hydroxy, includes fraction(s), if performed (CPT Code 82306) provided on August 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the complete series x-ray (D0210) provided on September 10, 2020.
You asked the Plan to pay the in network rate for the complete series x-ray. You say that you were told that the dental office was in network. You also say that you had to reschedule your appointment due to Covid-19. The Plan denied your request. The Plan says the complete series x-ray is not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the complete series x-ray (D0210) provided on September 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection procedure (20610) provided on October 1, 2020.
You asked the Plan to waive the copayment for the injection procedure. You say that you received an injection as part of an office visit with a specialist. The Plan denied your request. The Plan says the injection was billed as part of an outpatient surgery or procedure and has a $200 copayment.
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 $200 copayment for outpatient services provided at hospital outpatient facilities. You have been asked to pay a $200 copayment for the injection procedure. You stated that the injection procedure was part of an office visit with a specialist. Your Plan's 2020 EOC states that cost sharing will apply for additional services rendered during an office visit with your primary care provider or a specialist. An injection procedure provided at a hospital outpatient facility falls within the outpatient services provided at hospital outpatient facilities 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 injection procedure (20610) provided on October 1, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 admission toa SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee had COVID-19 and has been in an IRF. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs.He used oxygen via nasal cannula. His lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a supervision to touch assist level with functional mobility.  The enrollee required varying assist with activities of daily living.There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services ona daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the vision exam (92014) provided to you on October 9, 2020.
You asked the Plan to pay for the exam. You say that you have never been charged a copay. The Plan denied your request. The Plan says that only one exam is covered per year.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were provided for the exam by a contract provider. The file does not show that the Plan provided notice that the exam would not be covered. You went to the provider for a routine eye exam. The provider billed two eye exams for the same date of service, one for a new patient, and one for an established patient. You do not have control over how the provider codes and bills the services you were provided. You were provided the services with the reasonable expectation that the services would be covered under your plan. Under Medicare rules, this means the exam is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the vision exam (92014) provided to you on October 9, 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.

You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral primary osteoarthritis of the knees. He has not tried and failed the Plan's required drugs of Orthovisc and Monovisc. The records do not support that the required drugs would be less effective or contraindicated; therefore, Synvisc is not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. 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 pre-approve Synvisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora jaw immobilization and jaw CT scan (D7640, D0367) provided September 10, 2020 to September 11, 2020.You asked the Plan to pay forthe jaw procedure and CT scan. You say that the procedure was medically necessary.The Plan denied your request. The Plan says the billed services are not covered under your dental benefit. The reduction of the jaw fracture may be covered under your medical 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 fora jaw immobilization and jaw CT scan (D7640, D0367) provided September 10, 2020 to September 11, 2020.