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

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 1, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on July 1, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not approved in advance.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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on July 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

e decided that the Plan does not have to preapproveintermittent limb compression device.You asked the Plan to preapproveintermittent limb compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation failed to prove that sufficient evidence of four-week trial of conservative therapy.The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. A four-week trial of conservative therapy demonstrating failed response totreatment is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular home usage of conservative therapy including compression garments, exercise and elevation.Therefore, we decided that the Plan does not have to preapproveintermittent limb compression device
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on July 21, 2020.
You asked the Plan to waive the copayment for an injection. You say that you were not charged this much for prior injections. 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 $300 copayment for outpatient surgery/outpatient hospital. You have been asked to pay a $300 copayment for an injection. The injection you received is considered an outpatient surgery; therefore, the correct copayment has been applied. An injection falls within the outpatient surgery/outpatient hospital 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 outpatient surgery provided by a participating provider on July 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean inversion traction table for the enrollee.You asked the Plan to pre-approvethe table. You say that this is medically necessary.The Plan denied your request. The Plan says this is considered experimental.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 table. Our reviewer says that the requested table is considered medically reasonable and necessary in this case. Our physician reviewer found this item is not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. A review of the literature indicates that for low back pain  with or without radiculopathy, there is insufficient and a lack of high quality clinical evidence in the published, peer-reviewed scientific literature to indicate the effectiveness and safety ofhome traction. Additionally, you have hypertension and are on medications for hypertension. The recent document does not have a record of your blood pressure. The literature indicates both systolic and diastolic blood pressures increase significantly withinversion traction therefore there is no indication that this table would be safe for you to use.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 table havenot been met.Therefore, we decided that the Plan does not have to pre-approvean inversion traction table for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for post and core in addition to crown, indirectly fabricated, (D2952) for teeth # 23 and 26 provided on July 28, 2020.
You asked the Plan to pay for the dental services. You say that you do not believe that you needed these services. You say that your teeth are over three fourths of the height of normal teeth. You also say that since you feel you did not need these services, you should not have to pay for them. The Plan denied your request. The Plan says post and core in addition to crown, indirectly fabricated, is not listed as 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 for post and core in addition to crown, indirectly fabricated, (D2952) for teeth # 23 and 26 provided on July 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee on January 22, 2020.You asked the Plan to pay forhome health services. 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. The rules say that certain data elements on the RAP and the claimmust be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the billed charges are Home Health Skilled Nursing services and must be reported on HH PPS claims with the corresponding revenue code. Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee on January 22, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from January 2, 2020, to January 16, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from January 2, 2020, to January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 2, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because these services were medically necessary. The Plan denied your request. The Plan says these services are not eligible for telehealth, the billed codes are not appropriate for the services rendered and the claim was submitted with an incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Additionally, the claim was submitted with an inappropriate place of service code. The records indicate that the specimen was not collected in the laboratory, but in a home. Therefore, we decided that the Plan does not have to pay for laboratory services provided on January 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services rendered on August 23, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was billed incorrectly.The Plan must follow Medicare rules. The rules say that a RAP and a claim must be submitted for all episodes for which Medicare makes payment based on HIPPS codes. We looked at the file and Medicare rules. The file shows that the claim was not billed with a RAP. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home health services rendered on August 23, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF 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 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 the documentation does not support that you require at least 3 hours a day/5 days a week, or 15 hours over 7 consecutive days, of therapy services.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the portable oxygen concentrator warranty purchased.

You asked the Plan to reimburse you for the warranty. You say that the Plan paid for the warranty in the past.The Plan denied your request. The Plan says the Plan does not cover warranties purchased in anticipation of service needs.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. If you own your own equipment, Medicare will help pay for oxygen contents and supplies for the delivery of oxygen when all of the conditions are met. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to reimburse you for the portable oxygen concentrator warranty purchased.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on September 9, 2020.
You asked the Plan to pay for the vaccine. You say that you shouldn't have to pay for this. The Plan denied your request. The Plan says this is not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on September 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a LINX procedure (43284).
You asked the Plan to pre-approve a LINX procedure. 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. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a LINX procedure. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found whereas LINX implantation may meet FDA-indication and thus be appropriate for
some sufferers with refractory gastroesophageal reflux disease (GERD), the use of the device in the enrollee is
off-label, potentially contraindicated, and does not meet coverage 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 a LINX procedure have not been met. Therefore, we decided that the Plan does
not have to pre-approve a LINX procedure (43284).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gastric lipoma resection for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not indicate that the enrollee is experiencing symptoms at this time.
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 surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has multiple co-morbidities that place her at high risk for surgical procedures under sedation. The enrollee has a non-obstructing anterior wall lipoma that is of stable size and unremarkable histology. The risk/benefit ratio for this surgery in the enrollee's case is neither favorable, nor is it medically necessary at this time based on available records. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a gastric lipoma resection for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forarthrocentesis services billed with CPT code 20611 RT for date of service June 1, 2020.You asked the Plan to pay forthe arthrocentesis services. You say that the medical records provided support the service in dispute.The Plan denied your request. The Plan says the documentation does not contain evidence of permanently recorded images to support the billed charge.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 20611 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting.We asked our coding specialist 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 arthrocentesis services. Our reviewer says that the criteria for coverage have not been met. Our reviewer found code 20611 requires documentation of permanently recorded images to validate the service.  The medical records provide do not include documentation of permanently recorded images to validate this service.We looked at this coding specialist'sreview, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the arthrocentesis services have not been met.Therefore, we decided that the Plan does not have to pay forarthrocentesis services billed with CPT code 20611 RT for date of service June 1, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient office visit (99214) and presumptive drug class screening (80307) provided on April 13, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe office visit. You say that please review the attached supporting documentation as the services have been deemed payable.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 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 foroutpatient office visit (99214) and presumptive drug class screening (80307) provided on April 13, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance spectroscopy (76390).
You asked the Plan to pre-approve a magnetic resonance spectroscopy. You say that the services are necessary.
The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has
not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 a magnetic resonance spectroscopy.
Our reviewer says that the services are medically necessary. Our physician reviewer found you have frontal
lobe seizures and the presence of mild mass effect described on prior magnetic resonance imaging (MRI)
(report not in the submitted records) showed a possible malignancy. Since there is a possible malignant process
and mass effect has been described it would seem prudent to proceed with re scanning and biopsy now rather
than waiting another 5 months. Note that if the scan is unchanged or worsened biopsy would be definitely
indicated. If unchanged, biopsy would still be indicated due to the mass effect.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a magnetic resonance spectroscopy have been met. Therefore, we decided that
the Plan has to pre-approve a magnetic resonance spectroscopy (76390).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acupuncture services provided from June 26, 2020, to July 24, 2020.You asked the Plan to pay forthe acupuncture services. You say that you would like this claim reprocessed and approved for payment.The Plan denied yourrequest. The Plan says this is not a covered service according to the EOC.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the acupuncture services are being provided for chronic neck pain and not chronic lower back pain. Medicare only covers acupuncture services when provided for chronic lower back pain. In addition, the Plan does not provide any supplemental benefits for acupuncture.
Therefore, we decided that the Plan does not have to pay forthe acupuncture services provided from June 26, 2020, to July 24, 2020