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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and the complete series of radiographic images (D0210) received March 29, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and the complete series of radiographic images. You say that the Plan should pay for these services. The Plan denied your request. The Plan says you are limited to receiving one comprehensive oral evaluation every three years. There is no coverage for a complete series of radiographic images.
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 complete series of radiographic images (D0210) is not among those covered under this benefit. The Plan provides coverage for one comprehensive oral evaluation procedure every three years. The Plan has submitted evidence that this procedure was last covered by the Plan on September 5, 2019. When you received this service on March 29, 2021, your benefit was exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and the complete series of radiographic images (D0210) received March 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy provided on February 8, 2021 by an out-of-network provider.
You asked the Plan to pay for the psychotherapy. You say that the Plan should pay this claim. The Plan denied your request. The Plan says prior authorization was not 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 psychotherapy provided on February 8, 2021 by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325).
You asked the Plan to pre-approve Synvisc-One. You say that Synvisc-One is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc 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 Synvisc-One. Our reviewer says that
Synvisc-One is not medically necessary. Our physician reviewer found the record shows no trial of the plan
preferred drugs or any reason they would be unsafe or ineffective.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not
have to pre-approve Synvisc-One (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that this equipment is medically necessary. The Plan denied your request. The Plan says the item at issue in this appeal performs the same function as equipment that you currently use for your oxygen needs.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have home oxygen system. home oxygen system serves the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth specialist service provided on November 4, 2020.
You asked the Plan to waive the copayment for the telehealth specialist service. You say that you refuse to pay because you were not told there was a charge for a phone call. The Plan denied your request. The Plan says you were charged this copayment 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 $35 copayment for Physician Services. You have been asked to pay a $35 copayment for the telehealth specialist service. The telehealth specialist service falls within the Physician Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the telehealth specialist service provided on November 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee needs rehabilitation before chemotherapy. The Plan denied your request. The Plan says the guidelines for coverage have been met. The Plan says that the care needed can be received in another setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for established patient domiciliary, rest home visit (99337) provided on March 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for domiciliary, rest home visit. You say that your doctor is a hospitalist physician and depends on the hospital staff to verify eligibility and obtain proper authorization from the insurance companies. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 established patient domiciliary, rest home visit (99337) provided on March 1, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by White Haven Rescue Unit, Inc. on December 23, 2020.
You asked the Plan to waive the copayment for an ambulance trip. You say that this was an emergency situation, and this copayment should be waived. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for ambulance services/in-network/ground. You have been asked to pay a $275 copayment for an ambulance trip. The correct copayment has been applied to the services that were provided. An ambulance trip falls within the ambulance services/in-network/ground
benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance trip provided by White Haven Rescue Unit, Inc. on December 23, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for the duplex scan provided on October 29, 2018.
You asked the Plan to pay for the duplex scan. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services were not authorized.
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 referred for the duplex scan by a contract provider. The file does not show that the Plan provided notice that the duplex scan would not be covered. Under Medicare rules, this means the duplex scan is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the duplex scan provided on October 29, 2018.
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: Surgery
Decision: Favorable

We decided that the Plan has to waive the copayment for the shoulder surgery provided on February 10, 2021.
You asked the Plan to waive the copayment for the shoulder surgery. You say that you did not know there was a $150 copayment, and you cannot afford it. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for per visit. The Plan says you must pay a $150 copayment for the shoulder surgery. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the shoulder surgery. The Explanation of Benefits (EOB) shows the provider was the physician, not the facility. The record shows there are mismatching claim numbers. This means we cannot determine if the EOB and the claim form are for the same claim. Therefore, we decided that the Plan has to waive the copayment for shoulder surgery provided on February 10, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on September 2, 2020.
You asked the Plan to pay for the knee orthosis, adjustable knee joints (unicentric or polycentric), positional
orthosis, rigid support, prefabricated, off-the shelf (L1833LT) and addition to lower extremity orthosis,
suspension sleeve (L2397LT). You say that the orthoses were medically necessary. The Plan denied your
request. The Plan says this provider prescribed the orthoses without a face-to-face evaluation, physical
examination or imaging demonstrating medical necessity.
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 knee orthosis, adjustable knee joints
(unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf (L1833LT) and
Addition to lower extremity orthosis, suspension sleeve (L2397LT). Our reviewer says that the orthoses are not
medically necessary. Our physician reviewer found the documentation in the case file does not support that the
requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case,
according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or
recent surgical procedure on the enrollee's knee, there is insufficient credible objective documentation of joint
laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.
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 knee orthosis, adjustable knee joints (unicentric or polycentric), positional
orthosis, rigid support, prefabricated, off-the shelf (L1833LT) and addition to lower extremity orthosis,
suspension sleeve (L2397LT) have not been met. Therefore, we decided that the Plan does not have to pay for
the knee orthosis and suspension sleeve provided on September 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology exam represented by code 74019 provided on April 20, 2021.
You asked the Plan to pay for code 74019. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
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, we have confirmed that code 74019 has a bundled relationship with code 74022 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the radiology exam represented by code 74019 provided on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral exam (D0150) provided on January 21, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the dental services. You say that you are appealing the denial for payment for the services. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 comprehensive oral exam (D0150) provided on
January 21, 2021 by an out-of-network (OON) provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasonic guidance provided on February 26, 2021.
You asked the Plan to pay for ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation (76942). You say that the enroll had blind steroid injections with limited improvement this was the next logical step. The Plan denied your request. The Plan says the ultrasound guidance was not medically necessary.
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 pay for ultrasonic guidance for needle placement
(eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation (76942). Our
reviewer says that the service was not considered medically reasonable and necessary in this case. Our
physician reviewer found ultrasound guidance has been the subject of several studies and has variable efficacy
in performing a trigger finger injection, with several studies showing only partial laceration of the A1 pulley.
This would be considered experimental/ investigational and therefore, deemed not medically reasonable or
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 ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection,
localization device), imaging supervision and interpretation (76942) have not been met. Therefore, we decided
that the Plan does not have to pay for the ultrasonic guidance provided on February 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a wearable automatic external defibrillator (Life Vest, K0606) provided on December 31, 2020.
You asked the Plan to waive the coinsurance for a wearable automatic external defibrillator. You say that you were told at the time of issue of the requested item that Medicare would pay for it and you were under the assumption you would not have to worry about being charged for it. The Plan denied your request. The Plan says the correct coinsurance was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered durable medical equipment. You have been asked to pay $614.38, or 20% of the Medicare-allowed charge of $3,071.88, for a wearable
automatic external defibrillator. A wearable automatic external defibrillator falls within the "Durable medical equipment (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 a wearable automatic external defibrillator (Life Vest, K0606) provided on December 31, 2020.
Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibilities from the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. You say that you are unable to walk on your own. The Plan denied your request. The Plan says you no longer require skilled services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 continued services. Our physician
reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, and had
uncomplicated wound care. There are no identifiable skilled nursing service needs. Regarding rehab services,
you were at a contact guard to minimal assist level with bed mobility and transfers. You required varying assist
with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled
nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria
for an inpatient basis in a SNF setting.
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 services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued skilled nursing facility (SNF) services.