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

We decided that the Plan does not have to pre-approve chiropractic services (99204).

You asked the Plan to pre-approve the chiropractic services. You say that the services are medically necessary. The Plan denied your request. The Plan says chiropractic care is not covered in this case.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

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 chiropractic services Our reviewer says that the services were not medically necessary. Our physician reviewer found the only treatment allowed by Medicare for chiropractors is to treat a subluxation of the spine. The subluxation may be demonstrated by x-ray or by physical examination. The enrollees complaint is primarily in the left hip. Medical findings reveal normal findings, not supporting chiropractic treatment. 

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 chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic services (99204).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out of network (OON) provider.

You asked the Plan to pay for psychotherapy. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the assisted living facility is also out-of-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 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 psychotherapy provided by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services.

You asked the Plan to pay for the psychotherapy 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 psychotherapy 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 psychotherapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gingivectomy (D4210).

You asked the Plan to pre-approve the gingivectomy. You say that the service is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 gingivectomy when the services are medically necessary and reasonable. 

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 gingivectomy. Our reviewer says that the requested procedure is not medically necessary. Our physician reviewer found a review of the patient's dental record and radiographs do not indicate that periodontal scaling was done and only two teeth are present in the quadrant (#'s 1 and 5). Coverage criteria is not met for this procedure. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the gingivectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a gingivectomy (D4210).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a physician consultation to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physician consultation. The Plan denied your request. The Plan says that the Plan requires the enrollee to receive care from providers who are part of the enrollee's primary care physician's (PCP) specialty network. You must receive your care from a network provider. In most cases, care you receive from an out-of-network provider will not be covered.

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 a physician consultation to be provided by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the IV therapy (96365) and Natalizumab injection (J2323).

You asked the Plan to waive the coinsurance for the IV therapy and Natalizumab injection. You say that the coinsurance is too high. The Plan denied your request. The Plan says the cost sharing was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a total of $902.62 for the IV therapy and Natalizumab injection. IV therapy and Natalizumab injection fall within the Medicare 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 the IV therapy (96365) and Natalizumab injection (J2323).

Your complaint about you claim that you were billed a year after the services were provided 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 pre-approve a Vertiflex device.

You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition. Therefore, the Superion interspinous spacer (Vertiflex device) is not medically reasonable or necessary, for treatment of this enrollee's medical 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded 60100, 60100-59, 76942-26, and 60300.

You asked the Plan to pay for the medical 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 payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT codes 60100, 60100-59, 76942-26, and 60300 are not supported in the medical record. Specifically, one unit of each of these were previously approved and paid. There is no additional documentation supporting additional services which were billed. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded 60100, 60100-59, 76942-26, and 60300.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services.

You asked the Plan to pay for the lab services. You say that the test was ordered by your provider. The Plan denied your request. The Plan says that authorization was required, but not obtained.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.

You were referred for the lab services by a contract provider. The file does not show that the Plan provided notice that the lab services would not be covered. Under Medicare rules, this means the lab services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammogram.

You asked the Plan to pay for the screening mammogram. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you had a screening mammogram, therefore a second mammogram within 12 months is not covered.

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 screening mammogram, was requested solely for screening purposes. The Plan only covers one mammogram every 12 months. The record shows you had a mammogram in February. Therefore, we decided that the Plan does not have to pay for the screening mammogram.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit provided to the enrollee by an out-of-network provider.

You asked the Plan to pay for the DME. You say that you provided DME based on the prescription and the notes you received from the doctor. The Plan denied your request. The Plan says the services are not necessary for treatment of the enrollee's condition.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. There are no clinical notes from the enrollee's primary health provider. Medicare guidance says Medicare requires that the written order is completed after the face-to-face encounter. If the date of the written order is prior to the date of the face-to-face encounter, the contractor shall deny the claim. Therefore, we decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit provided to the enrollee by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out of network (OON) provider.

You asked the Plan to pay for psychotherapy. You say that you were under the impression you did have prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available 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 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 psychotherapy provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy services (97110, 97140).

You asked the Plan to waive the copayment for the physical therapy services. You say that you should not be charged a copayment. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each Medicare-covered therapy visit.

You have been asked to pay a $35 copayment for the physical therapy services. Physical therapy services fall within the Outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the physical therapy services (97110, 97140).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two comprehensive orthodontic treatments of the adult dentition.

You asked the Plan to pay for the comprehensive orthodontic treatments. You say that these services were due to a medical issue, and not a dental issue. The Plan denied your request. The Plan says these services are not covered because they are dental in nature.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the two comprehensive orthodontic treatments of the adult dentition.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection of anesthetic and/or steroid drug.

You asked the Plan to waive the copayment for the anesthetic/steroid injection. You say that you were not charged this amount for the same procedure in the past. The Plan denied your request. The Plan says the service took place at an ambulatory surgical center and therefore the correct cost share 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 $200 copayment for outpatient hospital services performed at an ambulatory surgical center. 

You have been asked to pay a $200 copayment for the anesthetic/steroid injection. The anesthetic/steroid injection falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the injection of anesthetic and/or steroid drug.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services.

You asked the Plan to pay for the surgical pathology services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these 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 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 surgical pathology services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a comprehensive hearing test (92557).

You asked the Plan to waive the copayment for a diagnostic hearing test. You say that you were charged a $10 copayment for what you thought was a routine hearing examination. You think you should not be responsible for the copayment. The Plan denied your request. The Plan says according to medical records, you received a diagnostic hearing test, and the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for outpatient diagnostic tests.

You have been asked to pay a $10 copayment for a diagnostic hearing test. The service at issue falls within the outpatient diagnostic tests 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 comprehensive hearing test (92557).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sclerotherapy.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation that the enrollee has significant discomfort or lifestyle limiting symptoms due to varicose veins. She was recently evaluated at the Clinic and intervention was not recommended. The sclerotherapy is not reasonable or medically necessary at this time. 

We looked at this physician's review, the file, and Medicare rules. 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 pre-approve sclerotherapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction you had on May 1, 2020. You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says this is not a network provider. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are provided by provided by a Vision network provider. We looked at the file and the Plan's rules. The eye refraction was not provided by a vision network provider. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction you had on May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third opinion consultation with an out of network provider.
You asked the Plan to pre-approve the physician services. You say that you were diagnosed with ALS. You say that you are aware there is no cure but will be applying wherever there is hope. You also say that you were seen and all they did was look at your legs without a flashlight, that is it. The Plan denied your request. The Plan says there are providers with your medical group that can provide the requested service.
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 physician services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the enrollee's Plan has network sufficiency with regards to the availability of neurologists and other providers who may be involved with the multidisciplinary management of a patient with ALS (e.g. neurology, pulmonary disease, PT/OT/ST, etc). Therefore, the request for an out of network consultation in this case would not meet the Medicare definition of medical necessity. 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 physician services have not been met. Therefore, we decided that the Plan does not have to pre-approve a third opinion consultation with an out of network provider.