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

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).You asked the Plan to pre-approve the dental item. You say that you last received an upper denture in 2019. You say that they no longer fit and are too big. You also say that you need a new upper denture in order to eat properly.The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit for dentures has been exhausted.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage and the complete upper denture is listed as a covered service, the frequency limit has been exhausted. The record shows that the Plan previously paid for the upper denture that you received on February 20, 2019.Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hearing services provided on January 15, 2019.
You asked the Plan to waive the copayment for hearing services. You say that you should not owe a copayment for routine hearing services. 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 $35 copayment for hearing services. You have been asked to pay a $35 copayment for hearing services. Hearing services fall within the hearing 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 copayment for hearing services provided on January 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 30, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 December 30, 2019.
Appeal type: Practitioner Services
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 October 28, 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 October 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on January 15, 2020.You asked the Plan to pay for the orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on January 15, 2020.
Appeal type: SNF
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 October 16, 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 October 16, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two additional home health physical therapy visits.You asked the Plan to pre-approve the additional visits. You say that this is medically necessary.The Plan denied your request. The Plan says the four approved visits have not been completed.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 the additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested visits are not generally accepted as specific and effective therapy for your condition. You are at moderate assist level of transfers, and ambulating fifty feet. You have had extensive therapy, and do not require ongoing skilled therapy for your condition. It is not likely that your goal of ambulating without pain will be met, given your history of osteoarthritis and chronic pain syndrome. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.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 additional visits have not been met.Therefore, we decided that the Plan does not have to pre-approve two additional home health physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 15, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record,his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided on November 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing provided on May 17, 2019.
You asked the Plan to pay for the testing services. You say that the testing is used to determine the best therapy option. The Plan denied your request. The Plan says the medical necessity of the testing for the enrollee's condition is not 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 pay for the testing services. Our physician reviewer found that understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing prognostic information, the value of next generation sequencing (NGS) to predict candidates for specific mutation-driven treatment holds promise, but is not yet ready for routine clinical use. Although the ability to decipher genomic aberrations in individual breast cancers to the single nucleotide resolution is now possible in both a timely and cost-achievable manner, there is a lack of data to show that this information can guide treatment decisions for patients with metastatic breast cancer. The use of NGS, such as with testing, continues to be the subject of ongoing clinical trials and use outside of a clinical trial at this time 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 the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the testing provided on May 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Hoveround power wheelchair (PWC).
You asked the Plan to pre-approve the PWC. You say that the enrollee would benefit from a PWC to assist in activities of daily living. The Plan denied your request. The Plan says there is not sufficient evidence of a mobility limitation that cannot be resolved with cane/walker/manual wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 PWC. Our reviewer says that the documentation provided does not support the medical necessity of the requested PWC. Our physician reviewer found review of multiple office visit notes over the course of 12/2019 through 05/2020 does not reveal any documentation of a mobility deficit that impairs participation in mobility-related activities of daily living (MRADL's). Multiple visit notes document "non-focal" neurologic findings on examination and a note of 01/06/2020 documents "normal gait and station" on examination and a review of systems at the time of this visit reports "no muscle weakness." A visit note of 05/13/2020 reports "needs wheelchair for ambulation" but there is no further detail on history or examination that clarifies if the mobility deficit impairs participation in mobility-related activities of daily living (MRADL's). 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 PWC have not been met. Therefore, we decided that the Plan does not have to pre-approve a Hoveround power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six chiropractic services.
You asked the Plan to pre-approve chiropractic services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 chiropractic services Our reviewer says that the documentation does not support that the requested chiropractic services are medically reasonable or necessary. Our physician reviewer found there are no submitted imaging studies to reveal evidence of a subluxation. The submitted chart notes/office visit, dated March 3, 2020 and March 30, 2020, reveal a history L1 spinal fracture, at age 30, due to a motor vehicle accident and recurrent left sacroiliac and lower lumbar pain, with findings of minimal kyphosis at T10-12 and slightly decreased ranges of motion (3/3/20) and pain at the paraspinal muscles at L3-5, guarded throracolumbar ranges of motion, with all negative orthopedic tests, rising on toes and heels, normal deep tendon reflexes and gait (March 30, 2020) revealing no evidence of subluxation per Medicare guidelines. In addition, the enrollee has no significant findings revealing that chiropractic intervention is necessary. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-approve six chiropractic services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on September 13, 2018 to May 21, 2019 by an out of network (OON) provider.
You asked the Plan to pay for podiatry services. You say that no authorization was obtained because the claim was originally submitted to Medicare as the patient's insurance. The Plan denied your request. The Plan says these services were self-referred. The Plan says that no prior authorization was obtained. The Plan says that these services were not 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 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 September 13, 2018 to May 21, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the back brace provided on December 19, 2019.You asked the Plan to waive the coinsurance for the back brace. You say that you were not told that the reimbursement amount would be reduced. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 30% coinsurance per out-of-network durable medical equipment (DME) item. You have been asked to pay $33.59 which is 30% of the allowed amount for the back brace. The allowed amount is $111.96. ($111.96 x 30% = $33.59). The back brace falls within the "Durable medical equipment (DME) and related supplies" benefit category. The record shows you were reimbursed $78.37. ($78.37 + $33.59= $111.96).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 back brace provided on December 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 5, 2020.You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the medical documentation indicates the specimen was obtained in an office setting.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.We find that the lab services were billed with a place of service code indicated for an independent laboratory (POS code 81). The documentation provided does not show that the actual place where the enrollee received face-to-face services was an independent laboratory. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services rendered on January 14, 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 billed correctly.
The Plan must follow Medicare rules. The rules say that for Medicare purposes, only one anesthesia code is reported unless the anesthesia code is an add-on code. We looked at the file and Medicare rules. The file shows that the enrollee received anesthesia services. The provider billed code 67500 (retrobulbar injection) for these services. This code is not the appropriate anesthesia code. 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 injection services rendered on January 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the injections, chemotherapy, and outpatient hospital services provided from September 19, 2019 to December 26, 2019.
You asked the Plan to waive the cost share for the injections, chemotherapy, and outpatient hospital services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received injections, chemotherapy and outpatient hospital services on the dates of service at issue in this appeal. The Plan says the correct cost share has applied per your contract with the Plan.
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 20% coinsurance for Medicare Part B prescription drugs and a $100 copayment for Outpatient hospital services. In this case, we looked at the file, the Plan's contract and Medicare rules. The file shows you received injections, chemotherapy and other outpatient hospital services on September 19, 2019, October 17, 2019, November 7, 2019, November 26, 2019, December 19, 2019, and December 26, 2019. You have been asked to pay a 20% coinsurance for the injections received on September 19, 2019, totaling $6.72, a 20% coinsurance for the injections received on October 10, 2019, totaling $1.59, a 20% coinsurance for the injections received on November 7, 2019 and November 26, 2019, totaling $4.09, and a 20% coinsurance for the injections received on December 19, 2019 and December 26, 2019, totaling $15.77. The injections fall within the Medicare Part B prescription drugs benefit category.
You have been asked to pay a $72.84 copayment for each outpatient hospital service received on September 19, 2019, October 10, 2019, November 7, 2019, November 26, 2019, and December 19, 2019, which is less than the contracted $100 copayment amount. You have been asked to pay your full $100 copayment for each outpatient hospital service received on October 17, 2019 and on December 26, 2019. These services fall within the Outpatient hospital services benefit category. This means that you have been asked to pay the correct amounts 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 cost share for the injections, chemotherapy, and outpatient hospital services provided from September 19, 2019 to December 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.You asked the Plan to pre-approve the compression stockings. You say that you require the stockings for blood clots in your legs.The Plan denied your request. The Plan says Medicare does not cover compression stockings at this billed code.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6533.