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

We decided that the Plan does not have to pay for the two first intraoral periapical x-rays and two palliative (emergency) treatments of dental pain provided on August 27, 2019 and February 25, 2020.
You asked the Plan to pay for the intraoral periapical x-rays and palliative (emergency) treatments of dental pain. You say that these services were a result of a bicycle accident. You also say that a molar was cracked at the time of the accident, which progressed to the point where it was necessary to extract. The Plan denied your request. The Plan says basic/major dental services are not covered under your 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 because they were not provided as part of a preventive visit. These services are not medical and also not preventive dental, which is the only thing the Plan covers. Therefore, we decided that the Plan does not have to pay for the two first intraoral periapical x-rays and two palliative
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for foot orthotics purchased on November 12, 2019.
You asked the Plan to reimburse you for foot orthotics. You say that because of your medical condition you cannot walk without the foot inserts. The Plan denied your request. The Plan says there is no face-to-face documentation or written order so this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records do not show that you suffer from diabetic foot disease or you wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to reimburse you for foot orthotics purchased on November 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided from October 18, 2019 to October 30, 2019. 
 
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says out of area services were not urgent or emergent. 
 
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 physical therapy provided from October 18, 2019 to October 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation stay provided from January 14, 2020 through January 18, 2020. 
 
You asked the Plan to waive the copayment for the observation stay. You say that she wasn't well enough to take care of herself. You say that she was sent home too soon from the initial stay. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for outpatient hospital observation services. 
 
The enrollee has been asked to pay a $250 copayment for the observation stay. The observation stay falls within the "Outpatient hospital observation" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the observation stay provided from January 14, 2020 through January 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a facet joint injection provided on
December 2, 2019.
You asked the Plan to waive the copayment for a facet joint injection. You say that you were not informed that
you would owe more than a $40 copayment and feel betrayed. 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 a $430
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and
ambulatory surgical centers.
You have been asked to pay a $430 copayment for a facet joint injection. A facet joint injection falls within the
outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical
centers 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 a facet joint injection provided
on December 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis.
You asked the Plan to pre-approve a knee orthosis. You say that the requested item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a knee orthosis is covered when specific criteria is met. 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 knee orthosis. Our reviewer says that the item is not medically necessary. Our physician reviewer found the request for the custom fabricated knee orthosis does not meet medical necessity criteria. The enrollee is ambulatory but the documentation does not reveal evidence of a recent left knee injury or surgery or evidence of left knee instability on a physical examination. 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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Biocept OncoCee Target Select Circulating Tumor Assay
provided on August 22, 2019.
You asked the Plan to pay for the Biocept OncoCee Target Select Circulating Tumor Assay. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services
rendered are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that all circulating tumor cells (CTC) assays are noncovered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Biocept OncoCee Target Select Circulating Tumor Assay have not been met. Therefore, we
decided that the Plan does not have to pay for the Biocept OncoCee Target Select Circulating Tumor Assay
provided on August 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric services rendered from January 22,
2020 to January 30, 2020.
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 the services were not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 pay for these services. Our reviewer says that the
services were not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital
with opiate use disorder, adjustment disorder, and uncomplicated opioid withdrawal. Based on the submitted
records, it was not expected that he would improve in a reasonable period of time, as he was not showing
dangerousness to himself or others and had no auditory or visual hallucinations. He had no behavioral issues or
withdrawal symptoms and was cooperative and compliant. It does not appear that active treatment was taking
place. The inpatient services were 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 pay for the inpatient psychiatric services rendered from January 22, 2020 to January 30, 2020.
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 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 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. In this case, you are requiring assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted. 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated stainless steel crown (D2931) provided on March 11, 2020.
You asked the Plan to pay for the prefabricated stainless steel crown. You say that this was a normal dental routine to save a tooth. You also say that the Plan wording is hard to find that this procedure is not covered, and you believe this procedure should be covered 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 prefabricated stainless steel crown (D2931) provided on March 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro 2 motion orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the device is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
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 orthotic device. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found at this time the requested robotic orthosis is not proven to be more beneficial for treatment of the patient's medical condition of hemiparesis after stroke than any available standard therapy. 
 
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 orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro 2 motion orthotic device (L8702).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ColoGuard testing rendered on November 13, 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 the testing is not covered.
The Plan must follow Medicare rules. Medicare rules say that ColoGuard is covered once every three years when specific criteria are met. We looked at the file and Medicare rules. The file shows that the enrollee previously received ColoGuard testing for which the Plan approved and paid fewer than three years from the date of service at issue. Therefore, we decided that the Plan does not have to pay for the ColoGuard testing rendered on November 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve the Prolia. The Plan denied your request. The Plan says this drug has been approved under the enrollee's Medicare Part D through December 31, 2020. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered 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 Prolia.  
 
Benefits for Prolia 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: 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 a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.
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 that the enrollee was admitted to an acute care hospital following a motor vehicle accident. He sustained multiple fractures and has undergone multiple surgeries. The enrollee is on a ventilator and has a tracheostomy in place. It is noted that the enrollee is quadriplegic and requires total assistance for transfers, bed mobility, and activities of daily living. Long-term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. 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 he is currently receiving care. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger provided on March 5, 2020.
You asked the Plan to pay for the perfusionist services (99190). You say that this equipment was provided to the enrollee during a surgery and should be covered. The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This equipment was used during a surgical procedure by the facility. Payment for this service would have been included under the facility claim. Therefore, the plan does not have to pay separately for assembly and operation of pump with oxygenator or heat exchanger provided on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for adult day care services (S5102) provided on September 4, 2019 through December 23, 2019. 
 
You asked the Plan to pay for the adult day care services. You say that you would like reconsideration for these services because they should be covered by the Plan. The Plan denied your request. The Plan says custodial care is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the adult day care services have not been met. Specifically, this service is considered custodial care and custodial care is not a covered benefit under Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for adult day care services (S5102) provided on September 4, 2019 through December 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on May 6, 2019. 
 
You asked the Plan to pay for drug test. You say that you are appealing with supporting documentation. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not support the lab service billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on May 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on January 14, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for podiatry services. You say that you were told that this provider was in-network. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for podiatry services provided on January 14, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewing x-rays a (D0272) and panoramic x-rays (D0330) provided September 25, 2019.
You asked the Plan to pay for the dental services. You say that You are being billed twice for services that were supposed to be completely covered. You was assured by the dentist office that any services provided to you would be at absolutely no cost to you. The Plan denied your request. The Plan says these services are not covered under the plan 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 bitewing x-rays a (D0272) and panoramic x-rays (D0330) provided September 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 20, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
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 September 20, 2019.