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

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis, the knee orthosis, and suspension sleeve provided by"the provider" on July 8, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis (L0650), the knee orthosis (L1851) and suspension sleeve (L2397). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says criteria for the orthoses were not met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunicationssystems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under theMedicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis, the knee orthosis, and suspension sleeve provided by "the provider" on July 8, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
September 3, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you had a diabetic eye
exam and it should be covered. 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 a $45
copayment for Medicare-covered vision services at an in-network specialist's office.
You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls
within the "Vision care" benefit category. The record shows you were charged for the office.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for the specialist office visit provided on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 12, 2019 by an
out of network provider.
You asked the Plan to pay for the pregnancy test (81025). You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says non-emergent services rendered by nonparticipating
facilities require prior authorization.
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 the medical services provided on September 12,
2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits (99213, 99204), a behavioral assessment (96127), and drug testing (80307) provided on July 31, 2019 to August 19, 2019 by the out of network provider.
You asked the Plan to pay for office visits, assessment and drug testing. You say that your practice will assist individuals to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capacities that are expected under patient medical necessity. You are requesting this information be taken into account and waive the denial of the claims. The Plan denied your request. The Plan says there was no prior authorization. The out-of-network provider must obtain prior authorization as outlined in the enrollee's EOC. These services were not authorized by the Plan or the member's primary care physician (PCP). The member self-referred, and the services were not found to be urgent in nature.
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 office visits (99213, 99204), a behavioral assessment (96127), and drug testing (80307) provided on July 31, 2019 to August 19, 2019 by the out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that while with your daughter you became unresponsive and an ambulance was called. When the responders arrived, you were helped to the ambulance and they ran tests and checked your vitals. You say that you were feeling better and the tests showed that everything was normal. You decided not to go to the hospital because you believed that your daughter could take you if needed later. You say that the Plan should cover the services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 5, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral
periapical x-ray, and panoramic x-ray provided on March 25, 2019 and April 23, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and
panoramic x-ray. You say that this provider is an in-network provider and your benefits are being applied
incorrectly. The Plan denied your request. The Plan says first intraoral periapical x-ray and panoramic x-ray are
not covered under your benefits. The Plan also says that you exceeded the number of evaluations that were paid
for the 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral
evaluation, first intraoral periapical x-ray, and panoramic x-ray are not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, first
intraoral periapical x-ray, and panoramic x-ray provided on March 25, 2019 and April 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for evacuation of meibomian glands (0207T) and unlisted special service (99199) provided on August 15, 2019.
You asked the Plan to pay for the vision services. You say that you've struggled with dry eyes for years and in order to get relief you had to use eye drops 8-10 times a day which would cause your vision to be impaired. This procedure was your last home for relief The Plan denied your request. The Plan says this service is not covered under 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 pay for the vision services. Our reviewer says that Our physician reviewer found 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 vision services have not been met. Therefore, we decided that the Plan does not have to pay for evacuation of meibomian glands (0207T) and unlisted special service (99199) provided on August 15, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90834) provided May 3, 2018 to March 8, 2019.
You asked the Plan to pay for the outpatient mental health services. You say that the services should be covered. The Plan denied your request. The Plan says the provider in this case is not eligible for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that Licensed Professional Counselors (LPC's) are not eligible for Medicare payment. We looked at the file and Medicare rules. The provider is not eligible for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services. have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90834) provided May 3, 2018 to March 8, 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 Plandenied 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 services are not medically necessary.Our physician reviewer found the review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Continuous Glucose Monitoring system (95251 and 95250) and an Autonomic Function Test (95923).
You asked the Plan to pre-approve a Continuous Glucose Monitoring system (95251 and 95250) and an Autonomic Function Test (95923). You say that the requested CGM and Autonomic Function Testing are medically necessary. The Plan denied your request. The Plan says Medicare criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. Medicare rules also say that therapeutic CGMs are covered when all of the above criteria are met. In this case, the file does not show that the enrollee has been using a BGM and performing frequent (four or more times a day) testing; and, the file does not show that the enrollee is insulin-treated with multiple (three or more) daily injections of insulin. The rules also say patient screenings without signs or symptoms of autonomic dysfunction, including patients with diabetes are considered not medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Autonomic Function Testing. Our reviewer says that the requested Autonomic Function Testing does not meet criteria. Our physician reviewer found the enrollee is with type 2 diabetes mellitus, A1c is greater than 14% and the enrollee is on orals medications; trulicty is prescribed. The record notes good pulses in feet and normal monofilament testing.
There is no documentation of why autonomic testing is being ordered (what symptoms the enrollee has or what will be done with the results of such testing). There is no rationale given in the chart or records as to why the autonomic testing is being ordered or how the information garnered from such testing will be used. Screening for this problem is not covered and without more information regarding why it is being done, it cannot be considered medically necessary or appropriate in this case 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 a Continuous Glucose Monitoring system (95251 and 95250) and an Autonomic Function Test (95923) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Continuous Glucose Monitoring system (95251 and 95250) and an Autonomic Function Test (95923).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services (99308) provided on June 27, 2019 by the out of network provider.You asked the Plan to pay forthe physician services. You say that the services were medically necessary.The Plan denied your request. The Plan says the plan has providers in-network. The services at issue were not emergent or preauthorized.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 forthe physician services (99308) provided on June 27, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ophthalmology services to be provided by out of network provider.You asked the Plan to pre-approve the ophthalmology services. You say that you drive 100 miles round trip to see this provider and he has provided great care and painless eye shots and you would like to continue seeing this provider.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says if an enrollee requires medical care that Medicare requires the plan to cover and there are no in-network providers who can provide the care then the enrollee can receive the care from an out-of-network provider. The plan has confirmed that there are in-network providers who are available to provide the 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 pre-approve 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. 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 the ophthalmology services to be provided by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that because of your medical conditions you are unable to stand in the shower. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214), and a glucose blood test (82962) provided on July 11, 2019 by out of network provider.You asked the Plan to pay for an office visit and a glucose blood test. You say that you are seeking a review and requesting payment.The Plan denied your request. The Plan says non-urgent services were not authorized because is a non-network provider with the member's health plan, and the member self-directed. The member's network primary care physician (PCP) did not refer for services. The health 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 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 an office visit (99214), and a glucose blood test (82962) provided on July 11, 2019 by out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on September 5, 2019.
You asked the Plan to pay for the radiology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 radiology services provided on September 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a balloon sinuplasty (30410).
You asked the Plan to pre-approve this service. You say that the procedure is medically necessary as the enrollee has chronic sinusitis. The Plan denied your request. The Plan says criteria has not been met for this procedure because the enrollee has not completed optimal medical therapy requirements which include antibiotic therapy for four or more weeks, a 3 month trial of inhaled nasal steroids, and there is no documentation of the use of nasal lavage or that an allergy assessment has been done.
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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the Surgery/Procedure Information Sheet lists multiple symptoms as well as medications tried. However, the clinical notes do not support multiple episodes of recurrent acute rhinosinusitis, with failure of medical management, including allergy evaluation nasal lavage, and a prolonged course of antibiotics. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve a balloon sinuplasty (30410).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you cannot stand long in the shower and need a
shower chair to prevent falling. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on March 7, 2019.You asked the Plan to pay forthe lab services. You say that the services were medically necessary.The Plan denied your request. The Plan says the billing diagnoses provided do not meet the coverage criteria.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The tests at issue in this appeal, the lab services, were requested solely for screening purposes, as evidenced by the billed diagnosis codes. Medicare does not cover this testing solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe lab services provided on March 7, 2019.