Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and a segmental pneumatic appliance (E0673) provided on December 11, 2020.
You asked the Plan to pay for a pneumatic compression device and a segmental pneumatic appliance. You say that the requested items were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The items at issue in this appeal were used only outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and a segmental pneumatic appliance (E0673) provided on December 11, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit (99283) provided October 27, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct amount 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 a $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the Emergency 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 for an emergency room visit (99283) provided October 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the inpatient hospital services provided from September 2, 2020, to September 4, 2020.
You asked the Plan to waive the copay for the inpatient services. You say that emergency room services are $90. The Plan denied your request. The Plan says the copay applied per your plan benefits.
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 $245 copay each day for days 1-6 for inpatient hospital care. You have been asked to pay a $245 copay each day for the inpatient services, totaling $490. The services fall 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 copay for the inpatient hospital services provided from September 2, 2020, to September 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy, anterior tooth (D3310) provided June 2, 2020.
You asked the Plan to pay for the root canal. You say that you were told the service was covered. The Plan denied your request. The Plan says that endodontic therapy D3310 is not a covered benefit according to the member's EOC booklet.
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 the endodontic therapy, anterior tooth (D3310) provided June 2, 2020.
Your complaint about potentially receiving misinformation from the Plan and/or dental provider about coverage 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services (97810, 97811) provided September 25, 2020 to October 9, 2020.
You asked the Plan to pay for the acupuncture services. You say that the services were medically necessary. The Plan denied your request. The Plan says rules for coverage were not met.
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, personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner. The documentation provided does not support that the services were properly supervised by a physician, physician's assistant or nurse practitioner. Therefore, we decided that the Plan does not have to pay for acupuncture services (97810, 97811) provided September 25, 2020 to October 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis Emu.
You asked the Plan to pre-approve Restasis Emu. The Plan denied your request. The Plan says this medication does not fall under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Restasis Emu.
Benefits for Restasis Emu may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem-focused oral evaluation (D0140) provided on December 3, 2020.
You asked the Plan to pay for the evaluation. You say that you needed a crown on your tooth. You did not feel you could trust your first dental provider because you say they were billing for services you did not receive, so you saw another dentist for the crown services. The Plan denied your request. The Plan says they have already paid for a problem-focused oral evaluation for you in the 2020 plan year. This service is only eligible for coverage once per year. The Plan also says that the Plan did not receive a claim or bill for the services you did not receive from the first dentist; they only received a request for prior authorization (permission) to complete the services.
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 problem-focused exam exceeded the annual frequency allowed by this benefit. Documentation was provided to show that the Plan already paid for a problem-focused evaluation in October of 2020. The documentation also shows that the only services billed by that provider on October 6, 2020 were x-rays and the exam to evaluate a specific problem. Therefore, we decided that the Plan does not have to pay for the problem-focused oral evaluation (D0140) provided on December 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Lucentis injection (J2778) provided November 19, 2020.
You asked the Plan to waive the coinsurance for the injection. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct amount 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 a 20% coinsurance for Part B drugs. You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Part B drugs 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 Lucentis injection (J2778) provided November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of lateral exostosis (D7471).
You asked the Plan to pre-approve the removal of lateral exostosis. You say that this request is medically
necessary. The Plan denied your request. The Plan says this is not a covered service under the Plan's
supplemental benefit.
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 pre-approve the
removal of lateral exostosis (D7471).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical cell stimulation and subcutaneous injection of a Nutri-Pharmaceutical blend (97112, 99212, J3490, 97032) provided October 8, 2020.
You asked the Plan to pay for the electrical cell stimulation and injections. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria was not 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 pay for the electrical cell stimulation and injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records provided did not show failure of physical therapy or record of nutrient deficiency to justify use of these therapies. 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 electrical cell stimulation and injections have not been met. Therefore, we decided that the Plan does not have to pay for electrical cell stimulation and subcutaneous injection of a Nutri-Pharmaceutical blend (97112, 99212, J3490, 97032) provided October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on September 11, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the subsequent nursing facility care,. You say that your physician provided medically necessary services to the enrollee in good faith. In consideration of the services rendered, your doctor is seeking reimbursement. 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 subsequent nursing facility care (99309) provided on September 11, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on July 27, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you should only pay a $35 copayment for the service. The Plan denied your request. The Plan says 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment for each Medicare-covered urgent care facility visit. You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The record shows you were seen at an urgent care facility. 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 urgent care visit provided on July 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a cardiovascular panel (81286, 81407, 81408, 81479) provided on October 10, 2020.

You asked the Plan to pay for a cardiovascular panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease.

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a cardiovascular panel have not been met. Therefore, we decided that the Plan does not have to pay for a cardiovascular panel (81286, 81407, 81408, 81479) provided on October 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this device is
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the rules for a
therapeutic continuous glucose monitor has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a
therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have
to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740), core buildup (D2950), and endodontic therapy (D3330).
You asked the Plan to pre-approve a porcelain/ceramic crown, core buildup, and endodontic therapy. You say that it is medically necessary for you to have this procedure. The Plan denied your request. The Plan says these are not covered services under your supplemental benefit.
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 pre-approve a porcelain/ceramic crown (D2740), core buildup (D2950), and endodontic therapy (D3330).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from October 16, 2020, to November 12, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient SNF level of care.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from October 16, 2020, to November 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion pump supplies (A4222) provided on February 15,
2020.
You asked the Plan to pay for infusion pump supplies. You say that the enrollee's treating physician chose to
utilize this infusion pump and supplies to treat the enrollee in the most clinically effective manner. The Plan
denied your request. The Plan says the denial of payment for these supplies is correct, because the enrollee's
antibiotic did not need to be given for more than 8 hours at a time.
The Plan follows Medicare rules. Medicare rules state that an infusion pump is only covered when certain sets
of criteria are met, and infusion pump supplies are only covered during the period of covered use of an infusion
pump.
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 infusion pump supplies. Our reviewer says
that these supplies do not meet the Medicare criteria for coverage. Our physician reviewer found the enrollee
underwent right total knee arthroplasty which was followed by a joint injection which requires a washing and
antibiotics for 6 weeks via peripherally inserted central catheter (PICC) line. The criterion for an infusion pump
is to require at least an 8-hour daily use, whereas the enrollee's antibiotic regimen does not require this and
therefore infusion without the pump is reasonable. Therefore, this request for associated infusion pump
supplies is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of infusion pump supplies have not been met. Therefore, we decided that the Plan
does not have to pay for infusion pump supplies (A4222) provided on February 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that you need SNF care to improve functioning.The Plan denied your request. The Plan says rules for SNF care have not been met because your needs are for custodial care.

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 you have a medical history including hypertension and heart failure and were admitted to an acute hospital due to a stroke. You have stabilized medically and have been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). You have tolerated inpatient rehab services and continue to make minimal progress with daily skilled nursing and/or skilled therapy services.There is no indication that transfer to a skilled nursing facility is required.There are no services offered at a SNF that are not offered at an inpatient rehab facility.

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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for external mobile cardiovascular telemetry with electrocardiographic recording (CPT code 93229) provided on September 4, 2020, by non-participating providers, Preventive Services.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the referring provider involved in these services is not a participating provider. The Plan states the services are not considered urgent/emergent in nature. The Plan states prior authorization was not obtained as required under the plan benefits.

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 external mobile cardiovascular telemetry with electrocardiographic recording (CPT code 93229) provided on September 4, 2020, by non-participating providers, Preventive Services.