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

We decided that the Plan does not have to pre-approve a power leg rest feature (E1012), an electronic connection (E2311), and a skin protection seat cushion (E2604).
You asked the Plan to pre-approve a power leg rest feature, an electronic connection, and a skin protection seat cushion. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested items are 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 power leg rest feature, an electronic connection, and a skin protection seat cushion. Our reviewer says that the requested wheelchair features are not medically necessary. Our physician reviewer found that, based on review of the records provided, the enrollee does not meet the coverage criteria for the requested wheelchair accessories. The documentation does not support medical necessity. 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 power leg rest feature, an electronic connection, and a skin protection seat cushion have not been met. Therefore, we decided that the Plan does not have to pre-approve a power leg rest feature (E1012), an electronic connection (E2311), and a skin protection seat cushion (E2604).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has back pain. The enrollee had an injection in 2019. The records submitted do not indicate that the current pain under treatment has been present for more than six month. The record indicates that the enrollee has improved with exercise and medication. The pain has not failed conservative care. The elements of the coverage criteria are not satisfied.
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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental periapical X-Rays provided on March 22, 2021.
You asked the Plan to pay for dental X-Rays. You say that this provider is in-network with the Plan, and your previous claims with this provider have been paid. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the Plan covered one periapical X-Ray and more than one periapical X-Ray per calendar year is not covered by the Plan's dental benefits. The Plan also says that they have reprocessed and approved payment for all other dental services on this claim, so this denial is only for the second and third periapical X-Rays (code D0230) you received.
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 periapical
X-Ray procedure per calendar year. We looked at the file, the Plan's rules, and Medicare rules. The Plan approved coverage for one periapical X-Ray procedure provided to you on March 22, 2021. Therefore, the Plan's benefit for periapical X-Rays was exhausted. Based on this information, we decided that the Plan's rules for coverage of dental X-Rays have not been met. Therefore, we decided that the Plan does not have to pay for dental periapical X-Rays provided on March 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wig purchased March 12, 2021 from a provider that is not enrolled in Medicare.
You asked the Plan to pay for a wig. You say that you would like this payment to be reprocessed by the Plan. The Plan denied your request. The Plan says this provider is not eligible to receive payment from Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a wig purchased March 12, 2021 from a provider that is not enrolled in Medicare.
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's rehabilitation and medical needs cannot be met at a lower level of care. The Plan denied your request. The Plan says the criteria for acute inpatient rehabilitation are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided at the current skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met because the requested level of care is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services
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 April 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 April 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically necessary. The Plan denied your request. The Plan says this procedure is considered experimental/investigational.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the outpatient clinic visit provided on January 14, 2021.
You asked the Plan to waive the cost share for the services provided. You say that the facility charge was supposed to be waived. The Plan denied your request. The Plan says you are responsible for the cost.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $395 deductible.
The outpatient clinic visit you asked the Plan to waive the cost share for falls within the outpatient hospital services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $395 deductible. This cost sharing is a contractual obligation that had not been met at the time the services were received. Therefore, we decided that the Plan does not have to waive the cost share for the outpatient clinic visit provided on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the specialist services provided from March 31, 2021, to April 2, 2021.
You asked the Plan to waive the copays for the services provided. You say that you were hospitalized as an inpatient. The Plan denied your request. The Plan says the claim processed 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 copay for each specialist visit, including outpatient clinic visits. The file shows that you received 3 specialist visits. The records do not indicate that you were admitted to the hospital as an inpatient. You have been asked to pay a $35 copay for each specialist visit. The services fall within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copays for the specialist services provided from March 31,
2021, to April 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power scooter purchased January 6, 2021.
You asked the Plan to pay for the power scooter. You say that this request was medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pay for the power scooter purchased January 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided December 22, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the services 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.
We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the
claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on
this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided December 22,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia provided on February 2, 2021.
You asked the Plan to pay for anesthesia. You say that you were told the service would be covered. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for anesthesia
provided on February 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoulder joint replacement surgery.
You asked the Plan to pre-approve shoulder surgery. You say that you are appealing with supporting records.
The Plan denied your request. The Plan says this procedure is not medically necessary, the enrollee has
multiple co-morbidities, and the safety of this procedure has not been established.
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 shoulder surgery. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found documentation is evident regarding significant co-morbidities for this procedure.
Furthermore, the computed tomography scan notes infection is not completely excluded. All other plausible
pain generators would need to be ruled out prior to undergoing a significant procedure. There is no compelling
rationale or extenuating circumstance noted to support the necessity of this request as an exception to
guidelines.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of shoulder surgery have not been met. Therefore, we decided that the Plan does
not have to pre-approve shoulder joint replacement surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has osteoporosis. She has not tried and failed the Plan's required drug, oral or intravenous (IV) bisphosphonate therapy. The records do not show that the required drug would be contraindicated or less effective; therefore, the Prolia 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 Prolia.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for WATS 3D biopsy testing provided on November 13, 2020.
You asked the Plan to pay for WATS 3D biopsy testing. You say that this testing was medically necessary. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this testing was not medically necessary.
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 physician. The file does not show that the plan provided notice that WATS 3D biopsy testing would not be covered. Under Medicare rules, this means WATS 3D biopsy testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for WATS 3D biopsy testing provided on November 13, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided September 16, 2020, the resin-based composite - one surface, anterior (D2330) and resin-based composite - two surfaces, anterior (D2331) provided September 22, 2020, and the full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided October 6, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the comprehensive oral exam, intraoral x-rays, resin-based composites and full mouth debridement. You say that you would like the services covered. The Plan denied your request. The Plan says the services have been covered according to 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 the comprehensive oral exam, intraoral x-rays, resin-based composites and full mouth debridement up to the maximum allowable charge (MAC). For services covered under the Plan, you may still be billed by an OON provider for any amount greater than the MAC payment made by the Plan to the provider. We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan. The Plan provided documentation showing that the services have been paid up to the MAC. Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral exam, intraoral x-rays, resin-based composites and full mouth debridement have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided September 16, 2020, the resin-based composite - one surface, anterior (D2330) and resin-based composite - two surfaces, anterior (D2331) provided September 22, 2020, and the full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided October 6, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 6, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that the visit was needed to evaluate the enrollee's current kidney function. 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 the office visit provided on April 6, 2021 by an out-of-network (OON) provider.