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

We decided that the Plan does not have to pay for the hereditary cardiovascular testing provided on October 24, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing, except the basic lipid panel.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. We looked at the file and the rules. In this case, there were insufficient medical records to show that the results of the testing would be used in the management of a specific medical problem. The testing was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular testing provided on October 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision testing services provided on November 13, 2020, by
an OON provider.

You asked the Plan to pay for the services provided. You say that the enrollee failed to inform you about a
change in insurance. 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 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 vision testing services provided on November 13, 2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth x-ray (D0210), the oral hygiene instructions (D1330), and the fluoride application (D1208) provided on March 5, 2021.
You asked the Plan to pay for the dental services. You say that you were asked to have an extra x-ray done at your appointment since the dentist was not there. You say that the office staff was very inattentive. You say that you do not understand why the dentist suggested braces if they were not covered. You also say that you do not trust this dental office. The Plan denied your request. The Plan says 1 full mouth or panoramic x-ray are covered per calendar year. The Plan says that the frequency limit has been exceeded. The Plan says that oral hygiene instruction is not listed as a covered service. The Plan also says that fluoride application is not listed as a covered service either.
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 and full mouth x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for the panoramic x-ray on this date of service, thus exhausting the benefit shared between 1 full mouth x-ray or panoramic x-ray. Additionally, oral hygiene instruction and topical application of fluoride are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full mouth x-ray (D0210), the oral hygiene instructions (D1330), and the fluoride application (D1208) provided on March 5, 2021.
Your complaint about your dissatisfaction with the dental office is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve elevator (stair lift) (CPT code A9270).

You asked the Plan to pre-approve the elevator (stair lift). You say that you are at high risk for falls. The Plan denied your request. The Plan says this durable medical equipment device for passive joint motion is not covered for any use other than after knee joint replacement surgery.

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 elevator (stair lift) have not been met. The Medicare rules state that elevators (stair lifts) are not covered. Therefore, we decided that the Plan does not have to pre-approve elevator (stair lift) (CPT code A9270).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 11, 2020.
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 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 by an out-of-network provider on February 11, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS Heart Failure (HF) System (CPT code(s): 33289 and C2624), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says that the services are considered experimental and investigational.

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 the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found given the severe symptoms of recurrent congestive heart failure (CHF) which appears very sensitive to volume loading conditions, complexity of the medical regimen and the failure to prevent acute CHF hospitalization in this patient, use of the CardioMEMS device is reasonable and has clinical data, expert opinion, and approved FDA indications to back up its use in selected appropriate clinical situations like this one. It would therefore meet the medical reasonableness and necessity criteria of the applicable CMS Section 1862(a) 1(A) rule and would not be considered investigational for this use. 

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 been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS Heart Failure (HF) System (CPT code(s): 33289 and C2624), for the enrollee.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on
February 8, 2021.
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that they told you there
was a concerning spot, but it was just a mole. You say that you should not pay the cost of the second
mammogram. The Plan denied your request. The Plan says the copayment 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 $35
copayment for each basic imaging service.
You have been asked to pay a $35 copayment for the diagnostic mammogram. The diagnostic mammogram
falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records
show a diagnostic mammogram was performed. 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 diagnostic mammogram provided on February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removal of torus palatinus (D7472).
You asked the Plan to pre-approve a removal of torus palatinus. You say that the requested procedure is necessary for your care. The Plan denied your request. The Plan says the requested procedure 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 service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a removal of torus palatinus (D7472).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (CPT 99291) provided to the enrollee on November 23, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 99291 (1 Unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We looked at the the file and Medicare rules. There is no documentation of the time spent providing the denied service. This is required, as CPT 99291 is a time-based code. 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 pay for critical care services (CPT 99291) provided to the enrollee on November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontics - porcelain/ceramic (D6245) for teeth 23, 24, 25 and 26 and retainer crowns - porcelain/ceramic (D6740) for teeth 22 and 27 to complete a six-unit fixed bridge as well as a bone replacement graft for ridge preservation (D7953) for teeth 5 and 15, and topical application of fluoride varnish (D1206).

You asked the Plan to pre-approve pontics for teeth 23, 24, 25 and 26, and white glass caps for teeth 22 and 27 to complete a six-unit fixed bridge as well as a bone graft and fluoride treatment. You say that you need the dental work done. The Plan denied your request. The Plan says the services are not covered under your benefits.

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 a pontic for teeth 23, 24, 25, 26 and white glass cap tooth for teeth 22 27 to complete a six-unit fixed bridge as well as a bone graft and fluoride treatment 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 pontics for teeth 23, 24, 25 and 26, and white glass caps for teeth 22 and 27 to complete a six-unit fixed bridge. Our reviewer says that the services do not meet the Plan's criteria for coverage. Our physician reviewer found that the submitted x-rays and claim information indicates that teeth #23,24,25 and 26 are to be replaced on the proposed bridge. Therefore, there are to be four teeth being replaced on the lower arch. Given the plan provisions, criteria are not met for the fixed bridgework being requested.

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 a pontic for teeth 23, 24, 25, 26 and white glass cap tooth for teeth 22 27 to complete a six-unit fixed bridge have not been met. Additionally, although the Plan offers dental benefits in excess of Medicare coverage, bone grafts and fluoride treatments (D1206) are not among the covered services. Therefore, we decided that the Plan does not have to pre-approve pontics - porcelain/ceramic (D6245) for teeth 23, 24, 25 and 26 and retainer crowns - porcelain/ceramic (D6740) for teeth 22 and 27 to complete a six-unit fixed bridge as well as a bone replacement graft for ridge preservation (D7953) for teeth 5 and 15, and topical application of fluoride varnish (D1206).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spiriva Respimat.
You asked the Plan to pre-approve Spiriva Respimat. You say that the enrollee has difficulty taking oral supplements. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Spiriva Respimat.
Benefits for Spiriva Respimat may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids (V5256) and related services (V5010, V5011) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the hearing aids and related services. You say that hearing aids are medically necessary for this enrollee. The Plan denied your request. The Plan says routine hearing services must be received from a provider in the specified hearing 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 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 Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for routine hearing services and hearing aids when they are purchased from a provider in the Plan's specified routine hearing network. The requested provider in this case is not part of the Plan's specified hearing network. The Plan's rules for coverage of hearing aids and routine hearing services have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids (V5256) and related services (V5010, V5011) to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on October 27, 2020.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.

This testing was ordered by an in-network provider. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on October 27, 2020.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the complete ultrasound examination of the
retroperitoneum (76770) provided February 4, 2021.

You asked the Plan to waive the co-payment for the diagnostic service. You say that you used to be charged $25
for ultrasounds in the past and was not expecting a $100 copay. The Plan denied your request. The Plan says
the claim was processed with the correct co-payment applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $100
co-payment for diagnostic radiology (CT, MRI PET scan ect.) services.

You have been asked to pay $100 co-payment for the diagnostic service. The diagnostic service falls within the
Outpatient diagnostic tests and therapeutic services and supplies 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 co-payment for the complete ultrasound examination of the retroperitoneum (76770) provided
February 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.

You asked the Plan to pre-approve the SNF services. You say that you live alone, and you cannot take care of yourself. You say that you have no feeling from the legs down, due to multiple sclerosis and this is causing very bad bed sores. The Plan denied your request. The Plan says the enrollee can safely receive the services needed in the current inpatient rehabilitation facility (IRF) setting.

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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that you have stabilized medically, and you have been receiving skilled rehabilitation services in an inpatient rehabilitation facility (IRF). You have tolerated inpatient rehabilitation services and you continue to improve with daily skilled nursing and/or skilled therapy services. You could benefit from continued services at the current level of care. You have made slow progress with therapy. There is no indication that transfer to a skilled nursing facility is required. You can continue to receive skilled rehabilitation services at the current IRF or be stepped down to a lower level of care when appropriate. There are no services offered at a SNF that are not offered at an IRF. Admission to a SNF for inpatient skilled rehabilitation services is not 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmology services provided on February 1, 2021 by an out of network (OON) provider.
You asked the Plan to pay for ophthalmology 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 by a participating 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 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 ophthalmology services provided on February 1, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection (Q5107, 96413) provided January 14, 2021.
You asked the Plan to waive the copayment for the injection. You say that the copayment wasn't applied in the past and should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $10 copayment and 20% coinsurance for specialist services and Part B drugs. You have been asked to pay a $10 copayment and 20% coinsurance for the injection. The injection falls within the specialist services and Part B drugs 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 injection (Q5107, 96413) provided January 14, 2021.