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

We decided that the Plan does not have to pre-approvean interspinousspacer placement (22869, 22870).You asked the Plan to pre-approvethe spacer placement. You say that the spacer placement is medically necessary.The Plan denied your request. The Plan says rules for coverage have 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 the spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Superion Vertiflex space is considered experimental at this time. More research is needed to show safety and efficacy.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 spacer placement have not been met.Therefore, we decided that the Plan does not have to pre-approvean interspinous spacer placement (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from December 6, 2019, through July 17, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. 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 did not pre-approve the physician's services. 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 physician's services provided from December 6, 2019, through July 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forout-of-network physician services provided to the enrollee on July 27, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out-of-network care.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 providerin 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 thePlan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forout-of-network physician services provided to the enrollee on July 27, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 12, 2020, by an out-of-network provider.You asked the Plan to pay forthe medical services. You say that the claim should be paid.The Plan denied your request. The Plan says this provider is not a network provider and the services were not referred by a network provider. The Plan states the services are not urgent or emergent, nor were they 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 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 forthe medical services provided on August 12, 2020, by an out-of-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330), the limited oral evaluation (D0140), the comprehensive oral evaluation (D0150), and the unspecified preventive service (D1999) provided from August 10, 2020, to August 12, 2020.
You asked the Plan to pay for the panoramic x-ray and unspecified preventive service. You say that you were never advised that the Plan only pays for the services you received every 5 years. You say that you did not know that the Plan would only pay for 1 oral exam per year. You say that the dentist called and was advised that the services would be covered at 100%. You say that you are on a budget and cannot pay for these services. The Plan denied your request. The Plan says panoramic x-rays are covered once every 5 calendar years. The Plan says that the frequency limit has been exceeded. The Plan says that the panoramic x-ray you received on March 15, 2019 was paid. The Plan also says that the unspecified preventive service 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 frequency limit of 1 panoramic x-ray every 5 calendar years has been exceeded. Additionally, the unspecified preventive service is not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330), the limited oral evaluation (D0140), the comprehensive oral evaluation (D0150), and the unspecified preventive service (D1999) provided from August 10, 2020, to August 12, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forpractitioner services provided to the enrollee on June 25, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare website shows the enrollee was enrolled in hospice from May 08, 2020 through current date. In accordance with Medicare guidelines, the provider needs to bill Original Medicare, using the proper modifiers, for services renderedon June 25, 2020. The claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice isrevoked. It is the provider's responsibility to verify the enrollee'scoverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forpractitioner services provided to the enrollee on June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve dynamic adjustable knee extension / flexion device, includes soft
interface material (CPT Code E1810).
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your
request. The Plan says that the device is not necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 device. Our reviewer says that the
requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found based on the medical records provided there is documentation that the dynamic adjustable knee
extension/flexion device, including soft interface material (CPT Code E1810) at issue in this case is medically
reasonable and necessary. Documentation was provided that the enrollee is participating on home health
physical therapy for reduced flexion and extension of the knee joint and as of the time of this review on
January 4, 2021, their surgery was more than three weeks ago (but less than four months ago).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the device have been met. Therefore, we decided that the Plan has to preapprove
dynamic adjustable knee extension / flexion device, includes soft interface material (CPT Code
E1810).
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 pre-approve the crown services (D2751) for tooth #29.

You asked the Plan to pre-approve the crown services. You say that this service is medically necessary due to your medical condition.The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crown services once per tooth every five years. 

We looked at the file and Medicare rules. The file indicates that you last had this service done on this tooth. This date is within five years which indicates coverage has been exhausted for the crown services. Based on this information, we decided that the Plan's rules for coverage of the crown services have not been met.Therefore, we decided that the Plan does not have to pre-approve the crown services (D2751) for tooth #29.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on July 7, 2020.
You asked the Plan to pay for the genetic testing. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says this service was not billed correctly.
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 genetic testing, was requested solely for screening purposes. The documentation does not show that the requested pharmacogenomic testing was ordered due to any signs/symptoms of a drug reaction. There is no evidence that the testing was provided for therapeutic decision-making regarding the need for the use of any specific drug. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic testing provided on July 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe automatic external defibrillator provided to the enrollee on December 7, 2018.You asked the Plan to pay forthe automatic external defibrillator. You say that you would like this claim reconsidered.The Plan denied your request. The Plan says that the claim was filed untimely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the automatic external defibrillator was not filed until June 20, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe automatic external defibrillator provided to the enrollee on December 7, 2018.
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 June 15, 2020.You asked the Planto waive the copayment for an outpatient surgery. You say that this procedure was cancelled and rescheduled. 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 $400 copayment for outpatient surgery/outpatient hospital facility. You have been asked to pay a $200 copayment for an outpatient surgery. Evidence was provided to show that the procedure was cancelled prior to anesthesia. Medicare rules state that the copayment is based on one-half the fullprogram copayment if the procedure is discontinued before anesthesia is induced. An outpatient surgery falls within the outpatient surgery/outpatient hospital facility 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 June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvethe MyoPro Motion G Orthotic device (CPT Code L8702).You asked the Plan to pre-approvethe device. You say that the member's arm remains unable to functionally bear weight.The Plan denied your request. The Plan says that your request is not medically necessary because this device has deluxe features that exceed the member's need and replaces, rather than improves the function of the member's arm.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found a request for MyoPro Motion G Orthotic device (CPT Code L8702) was made to improve overall right arm function. Robotic rehab is supported in the literature for permanent dysfunction such with this member. The MyoPro device requested would not be beyond what the member requires and is not excessive but would rather provide significant functional benefit. Therefore, this request for the MyoPro Motion G Orthotic device will be considered reasonable and medically necessary for the member'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 device have been met.Therefore, we decided that the Plan has to pre-approvethe MyoPro Motion G Orthotic device (CPTCode L8702).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 pre-approvetertiary orthopedic surgeon services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvetertiary orthopedic surgeon services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by a network provider.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-approvetertiary orthopedic surgeon services to be provided by an outof network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe partial upper denture (D5213).You asked the Plan to pre-approvethe partial upper denture. You say that this service is medically necessary.The Plan denied your request. The Plan says this service was last performed in February 2019 and you have exhausted your 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. The Plan covers partial upper denture services once per 60 months.We looked at the file and Medicare rules. The file indicates you last received this service in February 2019 therefore exhausting your benefits for partial upper denture for 60 months from this date of service. Based on this information, we decided that the Plan's rules for coverage ofthepartial upper denture have not been met.Therefore, we decided that the Plan does not have to pre-approvethe partial upper denture (D5213)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora lithotripsy provided on August 13, 2020.You asked the Plan to waive the copayment fora lithotripsy. You say that the surgery was not completed and you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery,including services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you received a lithotripsy on August 13, 2020. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for a lithotripsy. A lithotripsy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 fora lithotripsy provided on August 13, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on July 17, 2020, to August 13, 2020 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained for these services.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 forphysician services provided on July 17, 2020, to August 13, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown for tooth #25.
You asked the Plan to pre-approve the crown. You say that you never received a permanent crown, and believe the Plan already paid for it. The Plan denied your request. The Plan says this service exceeds the maximum count allowed.
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, you are limited to two crowns per year. The record shows that you received approval for 2 crowns on November 16, 2020, and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown for tooth #25.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on September 28, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you thought that you would not owe a copayment and would have seen your primary care physician instead if you had known. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each specialist visit. You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office 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 a specialist visit provided on September 28, 2020.