Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and the intraoral - periapical first radiographic image (D0220) provided October 1, 2020.
You asked the Plan to pay for the limited oral evaluation and intraoral x-rays. You say that you went to a network provider for necessary services and assumed you would not have a problem with insurance. The Plan denied your request. The Plan says the services are not covered under your dental 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 pay for the limited oral evaluation - problem focused (D0140) and the intraoral - periapical first radiographic image (D0220) provided October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral device/appliance provided on September 16, 2020.
You asked the Plan to pay for the oral device/appliance. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation is missing required information.
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 does not contain a valid proof of delivery for the supplies provided in this case. Review of the file shows that an itemized shipping/billing invoice was not provided to indicate the specific supplies. In addition, there is no corroboration between delivery ticket and proof of delivery. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the oral device/appliance provided on September 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast reduction surgery (19318).
You asked the Plan to pre-approve breast reduction surgery. You say that this should be covered. The Plan denied your request. The Plan says this is cosmetic.
The Plan follows Medicare rules. Medicare rules say that Medicare coverage of reduction mammoplasty is limited to those circumstances where the medical record supports medical necessity and reasonableness criteria described in the LCD. 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 breast reduction surgery. Our reviewer says that the requested procedure is not medically necessary. Our physician reviewer found the enrollee underwent breast reduction in September 2020. At this time, the enrollee is not having symptoms as required by the local coverage determination. The requested procedure is to further revise appearance and is cosmetic in nature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of breast reduction surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve breast reduction surgery (19318).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic radiographic images (D0330) received September 22, 2020 from the opt-out provider.
You asked the Plan to pay for the oral evaluation and radiographic image. You say that the Evidence of Coverage states that Non-Medicare dental services will be covered up to $525. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare, therefore the requested services are not eligible for coverage.
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. We verified that the provider in this case has opted out of Medicare. As such the requested services cannot be covered by the Plan. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic radiographic images (D0330) received September 22, 2020 from the opt-out provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided September 14, 2020. You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were medically necessary. The Plan denied your request. The Plan says there was no established relationship between the prescribing physician and the member.
The Plan follows Medicare rules. Medicare rules say that a knee orthosis and suspension sleeve are subject to the criteria listed in the Medicare rules section. 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 knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found the enrollee is a 74 year old woman with a history of bilateral knee pain from osteoarthritis who has not had surgery, recent injury, or physical therapy. In this case, the submitted documents do not establish objective evidence of knee instability, recent injury or surgical procedure. As a result, the elements of the coverage determination are not satisfied. 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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided September 14, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided on November 6, 2020.
You asked the Plan to pay for the emergency room services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
Medicare rules say any covered Medicare services not related to the treatment of the terminal condition for which hospice care was elected, and which are furnished during a hospice election period, may be billed by the rendering provider using professional or institutional claims for non-hospice Medicare payment. A/B MACs (A) and (B) process services coded with the GW modifier or condition code 07 in the normal manner for coverage and payment determination. In this case, the claim was not billed with an appropriate GW modifier. Therefore, we decided that the Plan does not have to pay for the emergency room services provided on November 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the amniotic fluid allograft injections to the left knee on May 21, 2020, to the left ankle on May 28, 2020, and to the right knee on July 7, 2020.
You asked the Plan to pay for the amniotic fluid allograft injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered were 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 pay for the amniotic fluid allograft injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the only medical record documentation provided are procedure notes. There is no diagnosis or reason for the treatment other than pain and stiffness. The medical necessity and reasonableness of the requester services cannot be established from the documentation provided. Therefore, the enrollee did not meet criteria for the services rendered. 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 amniotic fluid allograft injections have not been met. Therefore, we decided that the Plan does not have to pay for the amniotic fluid allograft injections to the left knee on May 21, 2020, to the left ankle on May 28, 2020, and to the right knee on July 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch test strips.
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied your request. The Plan says this is not the preferred brand.
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 test strips. Our reviewer says that the requested test strips are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, there is no medical documentation of why the preferred test strip brand is not appropriate. The request is for OneTouch test strips, a non-preferred brand. 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 test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve OneTouch test strips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous laser treatment.
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a failure of conservative therapy.
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 treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, although the enrollee has pain there is no edema and small calf varicosities - there is no evidence of ulceration, phlebitis, dermatitis or bleeding. The elements of the local coverage determination for symptomatic disease are not satisfied. The record indicates that the enrollee will not wear trial compression stockings. The documentation does not indicate other conservative therapy attempts. The requested service cannot be recommended. 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 treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous laser treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on November 5, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the item provided was medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained before these services were 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 when prior authorization was received. 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 the lumbar-sacral orthosis (L0650) provided on November 5, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walk-in shower provided October 5, 2020.
You asked the Plan to pay for the walk-in shower. You say that this item was medically necessary for the enrollee. The Plan denied your request. The Plan says this is not a covered item.
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 pay for the walk-in shower provided October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (CPT code E1390) and portable oxygen concentrator, rental (CPT Code E1392), for the enrollee.
You asked the Plan to pre-approve the supplies. You say that you are requesting review of denial of the supplies. The Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records show that the enrollee was experiencing a chronic lung disease exacerbation when prescribed oxygen, the enrollee's oxygen levels did not reach the level required, and no further testing was performed to demonstrate that the enrollee qualified for home oxygen. The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen. 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 supplies. Our physician reviewer found the coverage criteria for home oxygen are not met. The enrollee has chronic obstructive pulmonary disease (COPD). The enrollee was seen for a COPD exacerbation on March 3, 2021. On arrival, a single oxygen (O2) saturation measurement was 86% breathing room air. This increased to 93% on repeat, after resting. In order to meet criteria for supplemental oxygen, the low oxygen level must be correctable with supplemental oxygen. In this case, the low oxygen corrected itself. In order to qualify for home oxygen, the enrollee will need exercise oximetry and/or overnight oximetry, and any low oxygen levels shown to respond to supplemental oxygen. Without that documentation, oxygen is considered not medically necessary, and the denial is upheld. 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 supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (CPT code E1390) and portable oxygen concentrator, rental (CPT Code E1392), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Excimer laser therapy and photochemotherapy.
You asked the Plan to pre-approve Excimer laser therapy and photochemotherapy. You say that this treatment should be covered by the Plan. The Plan denied your request. The Plan says Medicare coverage criteria are not met. We overturned the Plans denial. The Plan requested a reopen and stated that we did not apply the correct criteria.
Our Medical Director reviewed the case file and the reopen request. At issue is coverage for Excimer laser therapy and photochemotherapy. Our Physician Reviewer determined that the requested services are considered medically reasonable and necessary in this case. The reviewer found the diagnosis is vitiligo, which is an indication for Excimer laser therapy and photochemotherapy based on community standards. The Plan argues that the services were directed at improving appearance and not for the repair of an accidental injury or to improve the functioning of a malformed body member. The Plan notes that Medicare excludes coverage of cosmetic services. Our Medical Director has concluded that the Plan is correct in this case. The documentation in the case file is conflicting, and overall does not support that the requested Excimer laser therapy and photochemotherapy were medically reasonable and necessary in this case. Clinical dermatology notes are lacking. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Excimer laser therapy and photochemotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve Excimer laser therapy and photochemotherapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency ambulance transport (CPT code A0110).
You asked the Plan to pre-approve non-emergency ambulance transport. You say that prior to enrolling in your plan you were advised by the brother that transportation services to your provider (four (4) hours away, about 226-286 miles one-way) would be covered. The Plan denied your request. The Plan says this request exceeds your mileage benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Your EOC states "this plan offers coverage for 150, one-way, routine transportation services every year. Trips are limited to 60 miles". After review it was determined that the distance you would need to travel is greater than the allowed amount of 60 miles per trip. Therefore, we decided that the Plan does not have to pre-approve non-emergency ambulance transport (CPT code A0110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight wheelchair.
You asked the Plan to pre-approve lightweight wheelchair. You say that a standard wheelchair is too heavy for you to lift so you will need a less heavy wheelchair. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because there is no evidence that you cannot self-propel in a standard wheelchair. The Plan follows Medicare rules. Medicare rules say that a lightweight wheelchair is covered if the enrollee meets the general criteria for a manual wheelchair and additionally the enrollee cannot self-propel in a standard wheelchair but can self-propel in a lightweight wheelchair. 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 lightweight wheelchair. Our reviewer says that you do not meet the Medicare criteria for the requested lightweight wheelchair. Our physician reviewer found the available records do not document that you cannot self-propel in a standard wheelchair. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lightweight wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from November 1, 2020, to November 30, 2020.

You asked the Plan to pay for the SNF services. You say that you were not aware of the prices. You say that you did not know that the initial charge of not paying was only for the first 20 days. You say that you did not think that you had to pay for the extension days as it was not indicated anywhere. You also say that you received a bill for $1,900. The Plan denied your request. The Plan says the copayment was applied correctly. The Plan also says that copayments cannot be waived.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay days 1 to 20 have a $0 copayment per day, per admission. Days 21 to 100 have a $172 copayment per day, per admission. for Skilled Nursing Facility (SNF) Care. 

The enrollee has been asked to pay a $0 copayment per day, per admission for days 1 to 20, and a $172 copayment per day, per admission for days 21 to 100 for the SNF services. The SNF services fall within the Skilled Nursing Facility (SNF) Care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from November 1, 2020, to November 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic testing provided by a participating provider on November 24, 2020.
You asked the Plan to waive the copayment for diagnostic testing. You say that you did not see the doctor. You say that you do not agree with this copayment. 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 $50 copayment for outpatient diagnostic tests/in-network/diagnostic tests/specialist's office. You have been asked to pay a $50 copayment for diagnostic testing provided in a specialist's office. The correct copayment has been applied to the services that were provided. Diagnostic testing falls within the outpatient diagnostic tests/in-network/diagnostic tests/specialist's office 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 diagnostic testing provided by a participating provider on November 24, 2020.