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

We decided that the Plan does not have to pre-approve a referral to you, an out-of-network provider, for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is needed due to continuation of care, and a plan of care established on 12/18/20. The Plan denied your request. The Plan says you are not a network provider within the benefit plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to you, an out-of-network provider, for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you have been receiving the stockings twice a year for several years. The Plan denied your request. The Plan says are noncovered because they do not meet the statutory definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET scan with concurrently acquired CT (whole body) for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary to investigate an unclear cause for weight loss. The Plan denied your request. The Plan says guidelines do not support a PET scan for the evaluation of unexplained weight loss.
The Plan must follow Medicare rules. Medicare rules say that PET 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee has had an extensive medical work-up, absent a recent colonoscopy. She has a documented weight that does not show a greater than 10% weight loss over the past few months. Her workup has been negative for malignancy. Her last chest x-ray on record was in 2017. Without a specific diagnosis of malignancy the criteria of medical necessity for PET/CT are not met. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET scan with concurrently acquired CT (whole body) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental implants for teeth 29, 30 (D6010) bone graft (D6104) and biologic material (D4265) provided October 21, 2019.
You asked the Plan to pay for the dental services. You say that you are requesting that the appropriate financial insurance benefit for tooth #30 be approved. The Plan denied your request. The Plan says these services are not covered under the plan benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental implants for teeth 29, 30 (D6010) bone graft (D6104) and biologic material (D4265) provided October 21, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services for a second opinion.
You asked the Plan to pre-approve the physician's services for a second opinion. You say that would like to receive a second opinion because you were not comfortable with other doctors and the diagnosis of bilateral cataracts. You say if you are seen at this practice and you are given the same diagnosis then you would move forward with the surgery. The Plan denied your request. The Plan says a second opinion for ophthalmology care is available within the health plan.
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 physician's services for a second opinion.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve varicose vein treatment.You asked the Plan to pre-approve the varicose vein treatment. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 varicose vein treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pain injection.
You asked the Plan to pre-approve a pain injection. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that repeat denervation procedures involving the same joint will only be considered medically necessary if the patient experienced > 50% improvement of pain and improvement in patient specific ADLs documented for at least 6 months. 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 pain injection. Our reviewer says that the requested injection is not medically reasonable and necessary. Our physician reviewer found that in this case, the last injections were done in December 2019 and a repeat injection is being requested less than 6 months later. 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 pain injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a pain injection.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on October 7, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe denied codes remain not supported.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve a power scooter. The Plan denied your request. The Plan says that you have a manual wheelchair that you are able to self-propel.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your condition can be improved by a manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wheelchair ramp.
You asked the Plan to pre-approve the wheelchair ramp. You say that you cannot use your legs anymore and you have 3 steps at your home and you need the ramp for your safety as the wheels of your chair are becoming loose. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the wheelchair ramp.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided from September 24, 2019 to September 26, 2019.You asked the Plan to waive the copayment forinpatient stay. You say that this hospital stay was for a revision surgery, so this copayment should be waived.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $265 copayment per day for days 1 to 8 and $0 copayment for additional days for inpatient hospital care. This inpatient staylasted 2 days, resulting in a copayment obligation of $530.You have been asked to pay $265 copayment per day for days 1 to 8 and $0 copayment for additional days for inpatient stay. Inpatient stay falls within the Inpatient Hospital Care 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 foran inpatient hospital stay provided from September 24, 2019 to September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed with mattress.
You asked the Plan to pre-approve a semi-electric hospital bed. You say that you need a semi-electric hospital bed because your current bed is very uncomfortable and you can't sleep. The Plan denied your request. The Plan says the records show you do not have the conditions listed for a semi-electric hospital bed.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. We looked at the file and Medicare rules. The medical records do not support criteria. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed with mattress.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for two retainer crowns (D6740) and a pontic (D6245).
You asked the Plan to pay for the retainer crowns and pontic. You say that a permanent bridge would be better for you than an implant. The Plan denied your request. The Plan says these procedures are not listed as covered by your 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. 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 two retainer crowns (D6740) and a pontic (D6245).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for x-rays and chiropractic services provided on October 21,
2019 to October 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for x-rays and chiropractic services. You say that you would like this appeal
reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was
obtained. The Plan says that there is no network deficiency for these services and alternate network providers
were found.
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 x-rays and chiropractic services provided on
October 21, 2019 to October 22, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for an out-of-network
provider.
You asked the Plan to pre-approve the referral. You say that this was at the request of your daughter who works
at the Clinic, and recommended this provider. The Plan denied your request. The Plan says the plan has
cardiothoracic providers 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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral to an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital hearing aids (V5261) purchased on August 29,
2019.
You asked the Plan to pay for the hearing aids. You say that you are requesting reimbursement of the hearing
aids purchased. The Plan denied your request. The Plan says enrollee's must receive their medical services
from an in-network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when services are received from a network hearing or hearing aid provider.
We looked the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage
of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the digital
hearing aids (V5261) purchased on August 29, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the pelvis.You asked the Plan to pre-approve the MRI. You say that this will help guide the biopsy.The Plan denied your request. The Plan says that there is no diagnosis of prostate cancer.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan did not provide any medical records for review to MAXIMUS. They did not substantiate their denial Therefore, we decided that the Plan has to pre-approve MRI of the pelvis.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on October 22, 2019.You asked the Plan to pay for the moderate sedation services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; therefore, the billed service cannot be verified.Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on October 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (70145) provided on June 14, 2019.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a chest radiograph shoulkd not be performed for screening purposes as part of a routine physical, preadmission or preoperative clearance examination in the absence of pertinent signs, symptoms or disease state.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.
The test at issue in this appeal, the chest x-ray, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for a chest x-ray (70145) provided on June 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3330) for tooth # 3 provided on November 26, 2019.You asked the Plan to pay for the dental service. You say that crowns are covered at 50%. You say that the root canal should also be covered at 50%. You also say that you contacted the Plan and no one could tell you why the service was not covered since it was part of a two part plan of service.The Plan denied your request. The Plan says root canals are 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 root canal is not among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are not covered.Therefore, we decided that the Plan does not have to pay for the root canal (D3330) for tooth # 3 provided on November 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home ventilator and filter provided on April 16, 2019.
You asked the Plan to pay for the home ventilator (E0466) and filter (A7038). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service.
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 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. There is no itemized shipping/billing invoice to indicate the specific supplies or Proof of Delivery indicating the billed items were delivered. Therefore, we decided that the Plan does not have to pay for the home ventilator and filter provided on April 16, 2019.