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

We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on October 8, 2020.
You asked the Plan to pay for the scaling. You say that this service should have been covered at 50% by the Plan. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
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 scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on October 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Medtronic Guardian Sensor 3 (A9276).

You asked the Plan to pre-approve the sensor. You say that this is medically necessary. The Plan denied your request. The Plan says that you are requesting a CGM product that is not FDA approved as therapeutic.

The Plan must follow Medicare rules. Medicare rules say that CGM devices covered by Medicare under the DME benefit are defined as therapeutic CGMs and code A9276 is used to describe the supplies used with a non-therapeutic CGM. 

We looked at the file and Medicare rules. Based on this information, we decided that you are requesting supplies for a non-therapeutic CGM. Medicare will only cover therapeutic continuous glucose monitors and supplies. Therefore, we decided that the Plan does not have to pre-approve the Medtronic Guardian Sensor 3 (A9276).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that this was a virtual visit for pain management. The Plan denied your request. The Plan says this care was not urgent or provided in an emergency, related to dialysis services, or approved prior to the date of service. The Plan does not cover out-of-network care outside of these circumstances.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit (99213) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95861, 95955, 95940, 95938,
95868, 95999) provided on May 3, 2019,
You asked the Plan to pay for neuromonitoring services. You say that your records indicate that this claim was
filed timely. The Plan denied your request. The Plan says this was filed more than a year after the date of
service.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for neuromonitoring services was not filed until July 10, 2020. This means that
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for neuromonitoring services (95861, 95955, 95940, 95938, 95868,
95999) provided on May 3, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Percutaneous Electrical Nerve Stimulator (PENS) placement (L8679, 64555).

You asked the Plan to pre-approve the nerve stimulator placement. You say that the PENS placement is medically necessary. The Plan denied your request. The Plan says this device is non-covered in this application.

The Plan must follow Medicare rules. Medicare rules say that Medicare reimbursement for acupuncture, as an anesthetic or as an analgesic, or for other therapeutic purposes, may not be made. 

We looked at the file and Medicare rules. The PENS device at issue is considered an electro-acupuncture device that uses needles through the skin and not electrodes, therefore it is non-covered. Based on this information, we decided that Medicare rules for coverage of the nerve stimulator placement have not been met. Therefore, we decided that the Plan does not have to pre-approve a Percutaneous Electrical Nerve Stimulator (PENS) placement (L8679, 64555).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the revascularization (37224) provided on July 28, 2020.
You asked the Plan to pay for the revascularization. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
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, the CPT Code Manual definition of code 37224 is revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty. We asked our coder 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 revascularization. Our reviewer says that CPT code 37224 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided to not include sufficient documentation to validate that a Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty was performed on July 28, 2020, therefore this procedure cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the revascularization have not been met. Therefore, we decided that the Plan does not have to pay for the revascularization (37224) provided on July 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Pneumatic Compression Device.

You asked the Plan to pre-approve the Pneumatic Compression Device. You say that the device is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that a 4-week trial of conservative treatment demonstrating a failed response to the treatment is required before the Pneumatic Compression Device can be approved. 

We looked at the file and Medicare rules. The record does not include any evidence of a 4-week trial of conservative treatment. The statement from the ordering physician notes that this has not been attempted. Based on this information, we decided that Medicare rules for coverage of the Pneumatic Compression Device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Pneumatic Compression Device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for respiratory virus detection (87633).

You asked the Plan to pay for respiratory virus detection. You say that you are not able to obtain prior authorization for services because you cannot access patient data. The Plan denied your request. The Plan says this services was performed for screening purposes.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal, respiratory virus detection, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for respiratory virus detection (87633).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of SNF services.
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the member is unable to care for themselves and needs 24 hour skilled nursing care. The Plan denied your request. The Plan says these services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of SNF services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing services provided by an out of network (OON) provider.

You asked the Plan to pay for the genetic testing services. 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 a covered benefit.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the genetic testing services provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea MyoPro Orthosis (L8702).You asked the Plan to pre-approvethe MyoPro Orthosis. You say that the orthosis is medically necessary.The Plan denied your request. The Plan says this device is considered investigation and is not covered.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 MyoPro Orthosis. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the device is not known to be effective, based on scientific evidence, professional standards, and expert opinion, in improving health outcomes. The MyoPro is not in widespread use based on scientific evidence and not the standard of care for post stroke hemiparesis.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 MyoPro Orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approvea MyoPro Orthosis (L8702).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance services.You asked the Plan to waive the copayment forthe ambulance services. You say that you were diagnosed with COVID and feel that it should be covered because it was due to COVID and other claims was approved due to COVID with the same provider.The Plan denied your request. The Plan says you were 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). Your contract with the Plan clearly says that you must pay a $240 copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $240 for these services. 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 forthe ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit with a specialist (99213) provided on November 2, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you do not feel it is fair to ask you to pay the specialist copay when you only saw someone at the office for five minutes. The Plan denied your request. The Plan says office visit services were provided, and specialist visits have a $45 copayment.
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 $45 copayment for physician and practitioner services provided by a specialist. You have been asked to pay a $45 copayment for an office visit. The office visit was provided by an orthopedic specialist and falls within the physician and practitioner services provided by a specialist 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 office visit with a specialist (99213) provided on November 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laser therapy services provided to the enrollee from July 14, 2020, to September 8, 2020.You askedthe Plan to pay forthe laser therapy services. The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that the use of infrared therapy devices and any related accessories is not reasonable and necessary. We looked at the file and Medicare rules. Per Medicare rules, the requested laser therapy services are not medically reasonable and necessary.Therefore, we decided that the Plan does not have to pay forthe laser therapy services provided to the enrollee from July 14, 2020, to September 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the diagnostic imaging services provided on August 24, 2020, and the surgical procedure provided on September 1, 2020.
You asked the Plan to reduce the copayments for the diagnostic and surgical services. You say that you were told by your provider's office that you would receive a discount if you paid part of the cost up front. The Plan denied your request. The Plan says the copayments for these services were applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for diagnostic imaging services provided in an outpatient hospital setting, and a $150 copayment for outpatient surgery services. You have been asked to pay a $150 copayment for diagnostic imaging services and another $150 copayment for a surgical procedure. 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 reduce the copayments for the diagnostic imaging services provided on August 24, 2020, and the surgical procedure provided on September 1, 2020.
Please note that we read your complaint about your claim to have additional discounts from the provider. This complaint is not a valid appeal for medical coverage. These issues are between you and the provider and do not involve your Plan or the Plan's contract. Medicare does not permit us to make a decision about these types of complaints. You may call 1-800-MEDICARE (1-800-633-4227) for help or more information about what you can do in this case. TTY users should call 1-877-486-2048.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance (D4910) provided on October 21, 2020.You asked the Plan to pay forthe periodontal maintenance. You say that you believe this service should be covered.The Plan denied your request. The Plan says your benefit 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 Plan offers a $500 annual maximum dental benefit. The contract clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility. The record shows that you metthe annual maximum benefit on October 21, 2020 and your annual maximum benefit has been exhausted.Therefore, we decided that the Plan does not have to pay forthe periodontal maintenance (D4910) provided on October 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plandoes not haveto pay forbronchodilation responsiveness services provided to the enrollee on July 16, 2020.You asked the Planto pay forthe services. You say that the right to recover for services provided to eligible beneficiaries is not extinguished by specific plan requirements.The Plandenied your request. The Plansaysthe revenue code and type of bill code used is not correct.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We find that the denied codes are not supported in the medical record. Specifically, the revenue code and type of bill code are not correctly used. There is no evidence of a corrected claim from the provider. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forbronchodilation responsiveness services provided to the enrollee on July 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9944).
You asked the Plan to pre-approve the occlusal guard. You say that the enrollee has extensive wear throughout her entire mouth. The Plan denied your request. The Plan says this service 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, 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 an occlusal guard (D9944).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete bilateral duplex scan (93925) for the enrollee.
You asked the Plan to pre-approve the scan. You say that the enrollee's exam was concerning for ocular ischemic syndrome. The Plan denied your request. The Plan says based on the records, an imaging test of the legs would not be 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 the scan. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee has symptomatology of ocular ischemia due to carotid artery disease. A lower extremity arterial duplex examination is not a medically necessary test to evaluate this condition. Therefore, criteria of the local coverage determination are not satisfied and the requested test cannot be recommended 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a complete bilateral duplex scan (93925) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have the referral a referral to an out-of-network OB/GYN provider.
You asked the Plan the referral the referral. You say that you have been seeing this provider for a very long time. The Plan denied your request. The Plan says this does not meet the continuity of care criteria.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 the referral the referral. Our reviewer says that the requested referral is not medically reasonable or necessary. Our physician reviewer found in this case, the plan has in network providers that can provide these services. The record does not indicate a medically sufficient reason for the enrollee to continue care with this provider. 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 referral have not been met. Therefore, we decided that the Plan does not have the referral a referral to an out-of-network OB/GYN provider.