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

We decided that the Plan does not have to pay for an annual wellness visit (G0439) provided on December 5, 2019.
You asked the Plan to pay for the annual wellness visit. You say that you would like reconsideration because you do not believe you received two annual wellness exams. The Plan denied your request. The Plan says per the EOC, an annual wellness exam is covered once every calendar year.
The Plan must follow Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the annual wellness visit have not been met. Specifically, the Plan contract clearly states that an annual wellness exam is covered once per calendar year. The record indicates that you received an annual wellness exam on November 14, 2019 and December 5, 2019. This exceeds the benefit limits. Therefore, we decided that the Plan does not have to pay for an annual wellness visit (G0439) provided on December 5, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aquatic therapy.
You asked the Plan to pre-approve these services. You say that you are in severe pain. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records show that you had right knee surgery on November 20, 2019 and were admitted to a skilled nursing facility (SNF) after the surgery for rehabilitation. You then had home-based therapy through December 4, 2019. The physical therapy reevaluation on March 10, 2020 states that your activity tolerance, mobility, ambulation, strength, transfers, and mobility were unchanged since the last evaluation on February 10, 2020. The records do not support that the requested aquatic therapy is considered specific and effective for your condition. The records do not show that you require the unique skills of a professional therapist are required to safely and effectively provide treatment. Aquatic therapy is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve aquatic therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block injection with moderate sedation.
You asked the Plan to pre-approve a genicular nerve block injection with moderate sedation. You say that the requested genicular nerve block injection with moderate sedation is medically necessary. The Plan denied your request. The Plan says the requested genicular nerve block injection with moderate sedation 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 genicular nerve block injection with moderate sedation. Our reviewer says that the requested genicular nerve block injection with moderate sedation is not medically necessary. Our physician reviewer found the review indicates that the enrollee is with a history of osteoarthritis of the right knee. On 2/10/10, she underwent right genicular nerve block x 3. She reported 80-100% relief for more than 8 hours. She is recommended to undergo right genicular nerve block/radiofrequency ablation x 3, with moderate sedation. Genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the requested genicular nerve block injection with moderate sedation is not medically reasonable and necessary for the enrollee 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 a genicular nerve block injection with moderate sedation have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block injection with moderate sedation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 2, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's 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 physician's services provided on October 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 medical services provided to the enrollee by an out-of-network provider on October 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses you received on August 19, 2019.
You asked the Plan to pay for the eyeglasses. You say that there is no indication that you must go to a network provider. The Plan denied your request. The Plan says the eyeglasses were purchased outside the plan's network of providers.
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. We looked at the file and the Plan's rules. The file shows that you received eyeglasses from a non-plan provider. Your contract says that eyewear is covered from a plan optical facility. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses you received on August 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on December 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.
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 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 lab services provided to the enrollee on December 24, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe positioning cushion you received on December 2, 2019.You asked the Plan to pay forthe provided item. You say that you are required to lay face down with this cushion.The Plan denied your request. The Plan says the service is not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipmentto 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 orinjured.Therefore, we decided that the Plan does not have to pay forthe positioning cushion you received on December 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea bridge for teeth # 8, 9, and 10.You asked the Plan to pre-approveon dental services. The Plan denied your request. The Plan says that you are missing back teeth. The Plan says that the bridge is not medically necessary.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 on dental services 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 on dental services. Our reviewer says that the requested fixed bridge does not meet the criteria for coverage. Our physician reviewer found the documentation provided shows there are multiple missing posterior teeth. Therefore the reviewer found that the fixed bridge for teeth # 8, 9, and 10 does not meetthe criteria for coverage.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 on dental services have not been met.Therefore, we decided that the Plan does not have to pre-approvea bridge for teeth # 8, 9, and 10.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CT scan to be provided by an out of network (OON) provider.You asked the Plan to pre-approvea CT scan. You say that you would like the planto reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by a network provider.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 providerwith the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvea CT scan to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvetympanostomy (69436) and nasal vestibular stenosis repair (30465).You asked the Plan to pre-approvetympanostomy and nasal vestibular stenosis repair. You say that you need these services due to your history of ear infections.The Plan denied your request. The Plan says that there is not a medical reason provided for these services.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve tympanostomy and nasal vestibular stenosis repair. Our reviewer says that the requested services are considered medically reasonableand necessary in this case. Our physician reviewer found the record shows that you suffer from chronic eustachian tube dysfunction (ETD) and have required multiple sets of pressure equalizing (PE) tubes. Given your history of ETD with recurrent effusions,it would be beneficial for you to keep the current left Tympanic Membrane (TM) perforation patent. This can be done with placement of a T-tube, which would also be more long-lasting than a regular PE tube. You do not need to have an effusion or TM retraction to benefit from PE tube placement. Your physical exam documentation also clearly indicates you have nasal valve collapse.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of tympanostomy and nasal vestibular stenosis repair have been met.Therefore, we decided that the Plan has to pre-approvetympanostomy (69436) and nasal vestibular stenosis repair (30465).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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 31, 2020 by an out of network (OON) provider.You asked the Plan to pay forpractitioner visit. You say that the facility requested this visit; therefore, medical necessity is pre-established.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 forthe medical services provided on January 31, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe knee replacement provided on November 18, 2019.You asked the Plan to waive the coinsurance forthe knee replacement. You say that you contacted the Plan prior to the procedure and were informed you were fully covered.The Plan denied your request. The Plan says the coinsurance 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 10% coinsurance for Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.You have been asked to pay $463.45, which is less than the standard 10% coinsurance for the knee replacement because you met your maximum out-of-pocket. The knee replacement falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. This means that youhave 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 forthe knee replacement provided on November 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveambulance services for the enrollee.You asked the Plan to pre-approveambulance services. You say that the member has a pacemaker and illnesses that prevent him from using any other means of transportation.The Plan denied your request. The Plan says that the enrollee does not meet ground ambulance requirement of being bed-confined in orderto receive transports to and from dialysis.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance services. Our reviewer says that ambulance services are not medically reasonable and necessary for the enrollee in this case. The documentation doesnot support that other means of transport are contraindicated for this patient for transportation for routine hemodialysis. The documentation also does not support that the patient needs the expertise, services and lifesaving and life-sustaining equipmentthat only a fully-equipped ambulance can provide for safe transport. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for ambulance 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 ambulance services have not been met.Therefore, we decided that the Plan does not have to pre-approveambulance services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation (D0120), the prophylaxis (D1110), the bitewing x-rays (D0274), the initial periapical x-ray (D0220), and 2 additional periapical x-rays (D0230) provided on November 4, 2019.You asked the Plan to pay forthe dental services. You say that you were advised by the dental office staff that the annual maximum and coverage for preventive dental services were 2 different things. You say that you were advised the services would be covered due to their preventive nature. You also say that had you known they would not be covered, you would have waited 2 months and they would have been covered.The Plan denied your request. The Plan says the annual maximum plan payment of $1,000 has been exhausted.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 maximum annual plan payment of $1,000 has been exhausted prior to receiving the services on November 4, 2019.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation (D0120), the prophylaxis (D1110), the bitewing x-rays (D0274), the initial periapical x-ray (D0220), and 2 additional periapical x-rays (D0230) provided on November 4, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency room care provided on November 12, 2019.You asked the Plan to pay forthe physician services. You say that the enrollee was not enrolled in hospice on the date of service.The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on November 1, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe emergency room care provided on November 12, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvethe insertion of a hypoglossal nerve stimulator (0466T, 64568).You asked the Plan to pre-approvethe insertion of a hypoglossal nerve stimulator. You say that this is covered under a proposed LCD.The Plan denied your request. The Plan says that this is not covered.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the insertion of a hypoglossal nerve stimulator. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found based on high-quality evidence published across different specialties, the hypoglossal nerve stimulator device should not be considered investigational or experimental. In addition, there is long-termdata that shows a reduction in the severity of obstructive sleep apnea, good patient compliance, a reduction in sleepiness, and improvement in quality of life. Finally, the success rate of the device is higher than other options that were presented by thehealth plan. You meet FDA criteria for the device. You have failed a CPAP trial and your apnea events are primarily obstructive.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rulesfor coverage of the insertion of a hypoglossal nerve stimulator have been met.Therefore, we decided that the Plan has to pre-approvethe insertion of a hypoglossal nerve stimulator (0466T, 64568).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.