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

We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on January 14, 2020.
You asked the Plan to pay for the DME. 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 when conducting a review of a covered DME item ordered by a physician, the Plan shall ensure that the physician saw the enrollee (including through the appropriate use of telehealth) and conducted a face-to-face assessment. We looked at the file and Medicare rules. The file does not contain documentation showing that the face-to-face encounter included information supporting the enrollee was evaluated or treated for a condition that supports the DME ordered. The file does not document that the face-to-face encounter was made prior to the written order. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Prolia injection provided on July 18,
2019.
You asked the Plan to waive the coinsurance for a Prolia injection. You say that the injection was approved so
you thought it would be covered. 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 20%
coinsurance for Medicare Part B prescription drugs.
You received a Prolia injection on July 18, 2019. The allowed amount is $1,228.26 and 20% of that is $245.65.
You have been asked to pay the total coinsurance amount of $245.65 for a Prolia injection. A Prolia injection
falls within the Medicare Part B prescription 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
coinsurance for a Prolia injection provided on July 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom myoelectric upper extremity (UE) orthosis.
You asked the Plan to pre-approve the custom prosthesis. You say that your provider indicates that standard rehab techniques and bracing have failed to improve your symptoms, so this device could help. The Plan denied your request. The Plan says your condition did not meet the Medicare rules for approval of a custom upper arm prosthesis.
The Plan follows Medicare rules. Medicare rules say that they will cover services that have proven benefit and are not experimental. 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 custom prosthesis. Our reviewer says that the service does not Medicare coverage for criteria. Our physician reviewer found the device does not have proven benefit and is considered experimental/investigational. It is not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language. 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 custom prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom myoelectric upper extremity (UE) orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve a specialist office visit. You say that you have used this doctor before. You
say that you would like to stay with this doctor. The Plan denied your request. The Plan says these services can
be provided in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 provider with 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-approve
a specialist office visit to be provided by an out of network (OON) provider.
Please contact the Plan for a list of in-network providers available for these services.
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 December 18, 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 December 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on November 27, 2019.
You asked the Plan to pay for the DME. 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 when conducting a review of a covered DME item ordered by a physician, the Plan shall ensure that the physician saw the enrollee (including through the appropriate use of telehealth) and conducted a face-to-face assessment. We looked at the file and Medicare rules. The file does not contain documentation showing that the face-to-face encounter included information supporting the enrollee was evaluated or treated for a condition that supports the DME ordered. The file does not document that the face-to-face encounter was made prior to the written order for the conditions listed on the written order. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) provided on November 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two office visits (99213) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve two office visits to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide this care. Therefore, coverage criteria has 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 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 provider with 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-approve two office visits (99213) to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the spine x-ray provided on October 31, 2019. You asked the Plan to waive the coinsurance for the spine x-ray. You submitted your bill for review. You say that you didn't choose an out-of-network provider. 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 30% coinsurance for out-of-network basic radiological services. You have been asked to pay $6.70, which is 30% of the allowed amount for the spine x-ray. The allowed amount is $22.32 (30% x $22.32 = $6.70). The spine x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the provider is out-of-network. 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 coinsurance for the spine x-ray provided on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0862) and accessories (E2377, E2313, E2323, E1007, E2621, E0955, E2311, E1012, E2208, E2363, E0956).
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the enrollee needs a group 3 power wheelchair and a group 2 would not be cost effective. The Plan denied your request. The Plan says the enrollee does not have an appropriate diagnosis for this device. The Plan must follow Medicare rules. Medicare rules say that a group 3 power wheelchair is covered if beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity. We looked at the file and Medicare rules. The submitted medical records do not show that the beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity. Based on this information, we decided that Medicare rules for coverage of a group 3 power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0862) and accessories (E2377, E2313, E2323, E1007, E2621, E0955, E2311, E1012, E2208, E2363, E0956).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride - excluding varnish and periodontal maintenance provided on January 13, 2020. 
 
You asked the Plan to pay for the topical application of fluoride and periodontal maintenance. You say that you had a dental cleaning and fluoride treatment and thought these services had some coverage. You also say that you are on a limited income. The Plan denied your request. The Plan says these services are not covered 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. 
 
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 topical application of fluoride - excluding varnish and periodontal maintenance provided on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 14, 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 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 physician's services provided on November 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF admission and the enrollee's caregiver states they are unable to care for the enrollee at his current level of function. The Plan denied your request. The Plan says the enrollee does not meet the criteria for an admission to an IRF. This request cannot be approved because care in an IRF exceeds member's medical needs. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require skilled physical therapy and occupational therapy but based on the medical records provided the patient does not require treatment in an intensive rehabilitation therapy program. The enrollee would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to deconditioning. A lower level of care would be more appropriate. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 28, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 laboratory 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 laboratory services provided on August 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on January
14, 2020.
You asked the Plan to pay for the DME. 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 when conducting a review of a covered DME
item ordered by a physician, the Plan shall ensure that the physician saw the enrollee (including through the
appropriate use of telehealth) and conducted a face-to-face assessment.
We looked at the file and Medicare rules. The file does not contain documentation showing that the face-to face
encounter included information supporting the enrollee was evaluated or treated for a condition that
supports the DME ordered. The file does not document that the face-to-face encounter was made prior to the
written order for the conditions listed on the written order. Therefore, we decided that the Plan does not have to
pay for the durable medical equipment (DME) provided on January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on March 21, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says codes 80307 and G0480 are 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.
In this case, the CPT Code Manual definition of code 80307 is presumptive drug testing, any number of drug
classes. The definition of code G0480 is definitive drug testing, 1-7 drug classes.
We find that CPT codes 80307 and G0480 are not supported in the medical record. Specifically, there is no
documentation of the method of testing utilized to support these codes. Based on this information, we decided
that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does
not have to pay for the drug testing rendered on March 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for two intraoral x-rays provided on November 21, 2019.
You asked the Plan to pay for the x-rays. You say that The Plan denied your request. The Plan says that your benefit provides coverage for one set of intraoral x-rays per calendar year.
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 one intraoral x-ray per calendar year. We looked at the file and Medicare rules. The file indicates the Plan has already covered one intraoral x-ray for this date of service. Based on this information, we decided that the Plan's rules for coverage of the x-rays have not been met. Therefore, we decided that the Plan does not have to pay for two intraoral x-rays provided on November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral-periapical, first x-ray (D0220) and intraoral-periapical, each additional x-ray (D0230) provided January 30, 2020.
You asked the Plan to pay for the dental x-ray. You say that the initial filling was on August 6, 2019. You returned to this dentist to have the filling refilled as your visit to another provider would not do the filling unless you did a root canal. The Plan denied your request. The Plan says the benefit frequency limit has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. This service is covered once a year. Records show that this service was provided January 21, 2020. 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 intraoral-periapical, first x-ray (D0220) and intraoral-periapical, each additional x-ray (D0230) provided January 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.
You asked the Plan to pre-approve home health aide services. You say that you need these services because you can't do things yourself. The Plan denied your request. The Plan says this is not medically necessary because you already have a personal care assistant.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 home health aide services. Our reviewer says that the criteria for coverage of the requested services has not been met. Our physician reviewer found based on the medical records provided the home health aide services are not reasonable and necessary to the treatment of an illness or injury by the skilled professional staff. They are duplicative based on the records provided. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services.