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

We decided that the Plan does not have to pay for lumbar-sacral orthosis (CPT Code L0650), Knee orthosis (L1833) and suspension sleeve (L2397) provided.

You asked the Plan to pay for the orthoses and sleeve. You say that the claim should be paid.The Plan denied your request. The Plan says the services are not supported by the records.

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 orthoses and sleeve have not been met. The Delivery Ticket 
submitted did not include the carrier's tracking number, nor did the Proof of Delivery include an order number or details to corroborate the Delivery Ticket submitted. Of note, the Proof of Delivery is not itemized to indicate the specific supplies; therefore, the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (CPT Code L0650), Knee orthosis (L1833) and suspension sleeve (L2397) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe incisional biopsy of oral tissue (D7285).You asked the Plan to pre-approvethe incisional biopsy of oral tissue. You say that these services are medically necessary.The Plan denied your request. The Plan says this is not a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those coveredunder this benefit.Therefore, we decided that the Plan does not have to pre-approvethe incisional biopsy of oral tissue (D7285).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepower adjustable seat (feature that raises and lowers the power wheelchair seat) (CPT Code E2300).You asked the Plan to pre-approvethe power adjustable seat. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says neither Medicare nor your Medicare Advantage health plan covers this item.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Therules say that a power seat elevation feature (E2300) is non-covered because they are not primarily medical in nature. 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 pre-approvepower adjustable seat (feature that raises and lowers the power wheelchair seat) (CPT Code E2300)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProcrit 10,000 unit/ml sol (J0885).You asked the Plan to pre-approveProcrit. You say that the services requested are medically necessary.The Plan denied your request. The Plan says rules for step therapy have not been met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Procrit. Our reviewer says that the services is not medically necessary and reasonable. Our physician reviewer found the Plan requires that Retacrit be used as a step therapy requirement. There is no evidence that the enrollee is allergic to or intolerant of Retacrit. There is no evidence that the enrollee has tried and not responded to Retacrit. There is no documentation as to why Retacrit would not be expected to be safe and effective for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met.Therefore, we decided that the Plan does not have to pre-approveProcrit 10,000 unit/ml sol (J0885).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental implant services (D6010) provided on July9, 2020.You asked the Plan to pay forthe dental implant services. You say that you would like these services calculated at 50%.The Plan denied your request. The Plan says these services are not covered and you must pay 100% for Class 3 Major 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 requested items or services are not among those covered under this benefit and you must pay 100% as specified in the EOC.Therefore, we decided that the Plan does not have to pay forthe dental implant services (D6010) provided on July 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean MRI of the left hip.You asked the Plan to pre-approvethe MRI. The Plan denied your request. The Plan says an MRI is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that an MRI of the left hip is not medically reasonable and necessary. Our physician reviewer found that the clinical records do not document on-going left hip pain. There are no clinical exam findings suggestive of hip pathology. Current evidence-based medical guideline criteria have not been met. There is no documentation that an initial imaging study of the pelvis/hip has been performed and found negative, equivocal or non-diagnostic. Therefore, this request for a left hip MRI is not medically reasonable and 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 the MRI have not been met.Therefore, we decided that the Plan does not have to pre-approvean MRI of the left hip.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on August 5, 2020 by an out of network (OON) provider.
You asked the Plan to pay for specialist services. You say that you would like this reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for specialist services provided on August 5, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe retainer crown (D6740) and pontic (D6245).You asked the Plan to pre-approvethe retainer crown and pontic. You say that these services are medically necessary.The Plan denied your request. The Plan says these are not covered 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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe retainer crown (D6740) and pontic (D6245)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe CT scan with CPT code 70450 provided on August 29, 2020.You asked the Plan to pay forCPT code 70450. 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.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forthe CT scan with CPT code 70450 provided on August 29, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (89050) provided on August 10, 2020.
You asked the Plan to pay for laboratory services. You say that this is supported by the records. The Plan
denied your request. The Plan says this was billed with an incorrect POS code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that the billing of this claim is not supported in the medical record. Specifically, this claim was billed
with POS 22 for an outpatient hospital, but the record indicates that the enrollee had an inpatient status at the
time this service was rendered. Based on this information, we decided that Medicare rules for coverage of
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory
services (89050) provided on August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive procedure (D1999) provided on
July 24, 2020.
You asked the Plan to pay for the unspecified preventive procedure. You say that you would like this claim
reprocessed and approved for payment. The Plan denied your request. The Plan says this service is not covered
under your dental rider.
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
unspecified preventive procedure (D1999) provided on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator.
You asked the Plan to pre-approve a spinal cord stimulator. 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 follows Medicare rules. Medicare rules say that spinal cord stimulators are only covered for certain
indications.
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 spinal cord stimulator. Our reviewer
says that the documentation does not support that the requested services are not medically necessary. Our
physician reviewer found you have chronic low back pain from a Failed Back Surgery syndrome also with
multi-level spinal stenosis. The documentation shows that you had a prior trial which did not improve your pain. It is unlikely that a new spinal cord stimulator would succeed where the past one did not. Therefore, you
do 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 a spinal cord stimulator have not been met. Therefore, we decided that the Plan
does not have to pre-approve a spinal cord stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on September 3, 2020.
You asked the Plan to pay for the first intraoral periapical x-ray. You say that the Plan gave you a letter approving the dental services to be provided out of network. The Plan denied your request. The Plan says this service is not a covered 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 first intraoral periapical x-ray provided on September 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe CardioMEMs device and procedure (CPT Codes: C2624 and 33289).You asked the Plan to pre-approvethe services. You say that the services are necessary.The Plan denied your request. The Plan says the member is not enrolled in an approved category B investigation study and a review of the current medical literature indicates that this service is considered experimental and investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.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 requestto pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance, therapy change based on data obtained from a CardioMEMsdevice has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met, since the device should still be considered experimental or investigational.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approvethe CardioMEMs device and procedure (CPT Codes: C2624 and 33289).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments foroutpatient hospital services provided on February 14, 2019, and March 27, 2019.You asked the Plan to waive the copayments foroutpatient hospital services. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for outpatient hospital services. You received outpatient hospital services on February 14, 2019. Therefore, you are responsible to pay the allowed amount of $102.68, which is less than the $275 copayment. You received outpatient hospital services on March 27, 2019. Therefore, you are responsible to pay the allowed amount of $102.68, which is less than the $275 copayment.The total amount you owe is: $205.36.You have been asked to pay the total amount you owe is: $205.36foroutpatient hospital services. Outpatient hospital services fall 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, wedecided that the Plan does not have to waive the copayments foroutpatient hospital services provided on February 14, 2019, and March 27, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forurgently needed services provided on July 1, 2020, and August 28, 2020.You asked the Plan to waive the copayments forurgently needed services. You say that you were paying a $0 copayment in the past and disagree with the increase in charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for urgently needed services. The medical records show that you received urgently needed services from July 1, 2020, to August 28, 2020, for a total of 3 visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40 (copayment) x3 (visits) = $120. You have been asked to pay a $40 copayment for urgently needed services. Urgently needed services fallwithin the urgently needed 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 copayments forurgently needed services provided on July 1, 2020, and August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on June 19, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for physician services. 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
rendering 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 has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for physician services provided on June 19, 2020 by
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean ultra-lightweight manual wheelchair and accessories.You asked the Plan to pre-approvean ultra-lightweight manual wheelchair and accessories. You say that a new chair would help maintain the enrollee's independence more effectively.The Plan denied your request. The Plan says the enrollee has a wheelchair which serves the same purpose as the requested wheelchair.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available toan enrollee, it is not considered reasonable and necessary.The file shows that the enrollee has manual wheelchair. The enrollee's current wheelchair serves the same purpose as an ultra-lightweight manual wheelchair and accessories. This wheelchair is still within the 5-year RUL and the documentation submitted does not show that thewheelchair is irreparably worn, irreparably damaged, or that the enrollee hashad a change in medical condition to warrant the scooter at issue. Based on the records provided,there is no indication that a replacement wheelchair meets Medicare coverage criteria. Medicare coverage criteria for a wheelchair replacement were not met.Therefore, we decided that the Plan does not have to pre-approvean ultra-lightweight manual wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cone beam CT capture and interpretation provided on August 4, 2020.You asked the Plan to pay forthe cone beam CT capture and interpretation. You say that you believed this x-ray would be covered, and do not feel like you should be held at fault.The Plan denied your request. The Plan says this service is not a covered 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. The records show that you contacted the Plan on July 21, 2020,to verify benefits, and were advised that this service was not covered.Therefore, we decided that the Plan does not have to pay forthe cone beam CT capture and interpretation provided on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 28, 2020, by an OON provider.You asked the Plan to pay fora domiciliary or rest home visit. You say that authorization should not be needed under telemedicine for payment of services rendered.The Plan denied your request. The Plan says rules for payment have not been met.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on July 28, 2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cone beam X-ray (D0364).

You asked the Plan to pre-approve cone beam X-ray. You say that this service is medically necessary.The Plan denied your request. The Plan says this service is not a covered 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 cone beam X-ray (D0364)