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

We decided that the Plan does not have to waive the copayment for the ambulance services (A0429) provided on January 2, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that the ambulance transport was grossly ill advised and the enrollee should not have to pay any cost share for this abuse and inconvenience. The Plan denied your request. The Plan says the enrollee was charged this cost sharing 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). The enrollee's contract with the Plan clearly says that the enrollee must pay a $330 copayment for each ambulance trip. The enrollee had 1 ambulance trip. The Plan charged the enrollee $330 for these services. 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 when enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance services (A0429) provided on January 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
You asked the Plan to pre-approve a pneumatic compression device. You say that the requested device is medically necessary. The Plan denied your request. The Plan says this device is not covered by Medicare.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider
from May 7, 2020, to June 23, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are
available in-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 services at issue in this appeal. 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 the services provided to you by an out-of-network provider from
May 7, 2020, to June 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of wireless pressure sensor into lung artery via catheter.

You asked the Plan to pre-approve insertion of wireless pressure sensor into lung artery via catheter. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 insertion of wireless pressure sensor into lung artery via catheter. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation shows that the enrollee has Stage D heart failure that indicates severe symptoms. The enrollee has a left ventricular assist device. The record does support that the enrollee has NYHA class III heart failure. The elements of the coverage criteria are not satisfied. Therefore, the enrollee does not meet criteria for the requested services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of wireless pressure sensor into lung artery via catheter have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of wireless pressure sensor into lung artery via catheter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural injection (64483).

You asked the Plan to pre-approve an epidural injection. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not had four weeks of conservative therapy.

The Plan follows Medicare rules. Medicare rules say that lumbar epidural injections are only indicated when there has been a failure of four weeks of non-surgical, non-injection care, which includes appropriate oral medications and physical therapy to the extent tolerated. 

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 an epidural injection. Our reviewer says that the requested epidural injection is not medically reasonable and necessary at this time. Our physician reviewer found the patient has not had a recent trial of physical therapy or of oral medications. None of the exceptions to the conservative therapy requirement have been met in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an epidural injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural injection (64483).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay more for the prophylaxis and periodic oral evaluation provided on February 8, 2021.
You asked the Plan to pay more for the prophylaxis and periodic oral evaluation. You say that your dental book does not state an out-of-network 50% copayment. The Plan denied your request. The Plan says the out-of-network coinsurance applied correctly.
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 Plan is only obligated 50% of the cost for a prophylaxis and oral evaluation. Therefore, we decided that the Plan does not have to pay more for the prophylaxis and periodic oral evaluation provided on February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and additional intraoral
periapical x-ray provided on December 10, 2020.

You asked the Plan to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray. You
say that you feel these services should be covered. The Plan denied your request. The Plan says your benefits
for this service have been satisfied and the frequency limitation has been exceeded.

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, intraoral x-rays are limited to one
procedure per calendar year. The record shows that you received two additional intraoral periapical x-rays on
December 10, 2020, one of which was covered by the Plan, and your intraoral x-rays benefit had been
exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray and
additional intraoral periapical x-ray provided on December 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthosis provided on October 14, 2020.
You asked the Plan to pay for the orthosis. You say that the enrollee was treated by the physician who provided medical notes. The Plan denied your request. The Plan says there are no claims on file with the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. The records in the case file do not support the billed services. The telehealth visit that correlates with the ordered orthosis was shown to occur on a date the enrollee was in the hospital. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the orthosis provided on October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on December 30, 2020.

You asked the Plan to pay for a panoramic radiographic image. You say that you were told that the provider was in-network and you want the Plan to pay. The Plan denied your request. The Plan says they have no record that you contacted the Plan prior to the date of service to verify benefits and provider eligibility. There is no coverage for when services are rendered by an out-of-network provider.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a panoramic radiographic image have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these 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 a panoramic radiographic image (D0330) provided on December 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services and inpatient stay
provided November 1, 2020, to December 11, 2020.

You asked the Plan to waive the copayment for the ambulance services and inpatient stay. You say that you
were severely misdiagnosed and should not be held responsible for charges. The Plan denied your request. The
Plan says the claims were processed, and the correct copayment was applied per the Evidence of Coverage.

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 $190
copayment for one-way covered ground ambulance services and $375 per day for days 1-6 and $0 for day 7
and after.

You have been asked to pay $2595.03 copayment for the ambulance services and inpatient stay. You had 2
ambulance services and was charged the $190 copay for both trips. You were also inpatient and was correctly
charged $375 per day. The ambulance services and inpatient stay falls within the Ambulance services and
Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the
ambulance services and inpatient stay provided November 1, 2020, to December 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery.

You asked the Plan to pre-approve Vertiflex Superion device placement surgery. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 Vertiflex Superion device placement surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has lumbar stenosis with neurogenic claudication. The Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. Therefore, the enrollee does not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex Superion device placement surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cardioaccelerator UPwalker.

You asked the Plan to pre-approve a Cardioaccelerator UPwalker. You say that this device is medically necessary. The Plan denied your request. The Plan says the requested item has deluxe features which exceed the member's need and provide an added convenience.

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 cardioaccelerator UPwalker. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Cardioaccelerator UpWalker has deluxe features that exceed your medical need. The documentation does not support that you require a built-in exercise machine with this walker or that this item would be safe and effective for your 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 Cardioaccelerator UPwalker have not been met. Therefore, we decided that the Plan does not have to pre-approve a Cardioaccelerator UPwalker.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) received December 7, 2020.
You asked the Plan to pay for the tooth extraction. You say that the requested service should be covered by the Plan. The Plan denied your request. The Plan says the requested service is not covered 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 pay for extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) received December 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device.

You asked the Plan to pre-approve the requested device. You say that the enrollee has failed more than 6 months of conservative approaches to treatment. The Plan denied your request. The Plan says the device is not covered until it's efficacy has been established.

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 requested device Our physician reviewer found that the interspinous spacer device remains experimental at this time. More research is needed to show safety and efficacy of the device. Therefore, the requested services are not medically reasonable and 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 the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular risk analysis provided on
November 9, 2020.

You asked the Plan to pay for the services provided. You say that cardiac genetic tests are medically necessary
when determining hereditary cardiac conditions. The Plan denied your request. The Plan says the enrollee was
not found in the provider's system.

The Plan must follow Medicare rules. Medicare rules say that all diagnostic tests must be ordered by the
physician who is treating the enrollee.

The file does not contain documentation of an established relationship between the enrollee and the ordering
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this
testing have not been met. Based on this information, we decided that Medicare rules for coverage of the
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the
hereditary cardiovascular risk analysis provided on November 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a
participating provider on December 22, 2020.

You asked the Plan to waive the copayment for an ambulance trip. You say that the doctor did not want you to
drive so you called an ambulance. 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 $225
copayment for ambulance services/ground transportation.

You have been asked to pay a $225 copayment for an ambulance trip. The correct copayment has been applied
to the services provided. An ambulance trip falls within the ambulance services/ground transportation 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 ambulance trip provided by a participating
provider on December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on December 12, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the diagnosis codes are not supported.

The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. 

We looked at the file and Medicare rules. The file shows that procedure code 99223 (initial hospital care) was billed with mismatched diagnosis codes. 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 pay for the initial hospital care rendered on December 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you no longer require daily skilled services.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on December 9, 2020.

You asked the Plan to pay for the assistant surgeon services. The Plan denied your request. The Plan says this type of provider is not payable for these services.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. 

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on December 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), cleaning (D1110) and bitewing x-rays (D0272) provided on December 1, 2020 by an out-of-network provider.

You asked the Plan to pay for the dental services. You say that you did not know that this provider was not in the Plan's network. If you receive services out of network, you will be responsible for 100% of the cost. The Plan denied your request. The Plan says out-of-network dental care is not covered.

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, items or services received out-of-network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), cleaning (D1110) and bitewing x-rays (D0272) provided on December 1, 2020 by an out-of-network provider.