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

We decided that the Plan does not have to pre-approve diabetic shoes to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve diabetic shoes. You say that you would like approval for this equipment. The Plan denied your request. The Plan says there are in-network providers available 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve diabetic shoes to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services and lab work provided on July 7, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician services and lab work. You say that you would like this claim reprocessed and paid. 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 physician services and lab work provided on July 7, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).

You asked the Plan to pre-approve a Dexcom G6 CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested Dexcom G6 CGM is not medically necessary. The Plan says that they only cover FreeStyle Libre CGMs.

The Plan must follow Medicare rules. The rules say that a Medicare Health Plan must disclose to its members the benefits offered under the plan including applicable conditions and limitations. 

We looked at the file, the Plan's contract and Medicare rules. The Plan only covers FreeStyle Libre CGMs. The Plan will not cover other brands unless your provider tells us it is medically necessary. Your provider has not shown that the requested non-preferred brand CGM is medically necessary over the Plans preferred brand CGM. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a 3D rendering with interpretation post processing (76376).
You asked the Plan to pre-approve a 3D rendering with interpretation post processing. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says that the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan sent us a case file that contained documents for the incorrect enrollee. The only information we have from the Plan for this enrollee is the Part C Case File Submission form. We sent a request to the Plan for the corrected case file with no response. We find that the Plan has not provided enough information to substantiate the Plan's denial. Therefore, we decided that the Plan has to pre-approve a 3D rendering with interpretation post processing (76376).
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. (A9283)
You asked the Plan to pre-approve foot orthotics. You say that the foot devices are medically necessary. The Plan denied your request. The Plan says 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 show that you do not suffer from diabetic foot disease and you do not 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 pre-approve foot orthotics. (A9283)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the topical application of fluoride varnish (D1206), the gingival irrigation - per quadrant (D4921), and the clinical crown lengthening - hard tissue (D4249).
You asked the Plan to pre-approve the dental services (D1206, D4921, D4249). You say that these are medically necessary dental services. The Plan denied your request. The Plan says the requested services are not covered under your supplemental 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 pre-approve the topical application of fluoride varnish (D1206), the gingival irrigation - per quadrant (D4921), and the clinical crown lengthening - hard tissue (D4249).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin B12 assay provided on October 5, 2020, billed with code 82607.

You asked the Plan to pay for the vitamin B12 assay. You say that this test was medically necessary as ordered by the treating provider. The Plan denied your request. The Plan says this test was provided already in 2020 and cannot be paid more than once without evidence of vitamin deficiency or malabsorption.

The Plan must follow Medicare rules. Medicare rules say that separate payment cannot be made for lab services that are related to ESRD treatment. Code 83607 is listed as a test that is always included on the ESRD facility claim, unless billed with modifier AY. 

This test was not billed with modifier AY. As such, it must be included in the facility claim and is included in the ESRD PPS payment to the facility. Therefore, we decided that the Plan does not have to pay for the vitamin B12 assay provided on October 5, 2020, billed with code 82607.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of impacted cerumen provided on February 11, 2021 billed with two codes 69209-RT and 69209-LT.
You asked the Plan to pay for the cerumen removal services as billed. You say that this was correctly billed to reflect the service was performed on both ears. The Plan denied your request. The Plan says two units were billed and there is an absolute MUE of 1 per date of service for this code. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 69209 is one unit with an MAI of 2. You billed two units of this code, exceeding the MUE. Although this can be provided bilaterally, the MUE of 1 requires one line item with the -50 modifier to be used. Based on this information, we decided that Medicare rules for coverage of the cerumen removal services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the removal of impacted cerumen provided on February 11, 2021 billed with two codes 69209-RT and 69209-LT.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical services to be provided at an out of network (OON) facility.
You asked the Plan to pre-approve surgical services to be provided at an OON facility. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network facilities available to you that can provide the surgical services you are requesting.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve surgical services to be provided at an out of network (OON) facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new patient visit (99205) and eye exams (76514, 92025, 92136) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve services with a new provider. You say that you saw this provider years ago for a similar issue and would prefer to see them again because they are familiar with your history. The Plan denied your request. The Plan says out-of-network services are generally not covered by your Plan. The requested care can be provided in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a new patient visit (99205) and eye exams (76514, 92025, 92136) to be provided by an out of network (OON) provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.
You asked the Plan to pre-approve massage therapy. You say that your doctor prescribed massage therapy for your neck treatment because physical therapy has not helped your condition. The Plan denied your request. The Plan says massage therapy is excluded with the Plan per Medicare Guidelines.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and drug test provided on July 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit and drug test. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
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 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 office visit and drug test provided on July 22, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper overdenture (D5863), an upper partial denture (D5225), and precision attachments (D5862 x2).
You asked the Plan to pre-approve a complete upper overdenture, an upper partial denture, and precision attachments. You say that you have a limited income and want the Plan to cover the services. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete upper overdenture (D5863), an upper partial denture (D5225), and precision attachments (D5862 x2).
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 are appealing because you have extreme edema in your right leg. The stockings need to be custom fit. Your surgeon ordered these particular stockings. The Plan denied your request. The Plan says these dressings are noncovered under the surgical dressing benefit.
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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the CT scans provided on December 1, 2020 and December 5, 2020.
You asked the Plan to waive the copayments for the CT scans. You say that you were told there would be no charge when you went back for the second CT scan. The Plan denied your request. The Plan says you have been asked to pay 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 $175 copayment for in-network CT scans.
You have been asked to pay a $175 copayment for the CT scan on each date of service. The CT scans fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the CT scan on the right arm and the CT scan on the left arm are considered two separate procedures.
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 copayments for the CT scans provided on December 1, 2020 and December 5, 2020.
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 you need ten days of physical therapy in an IRF. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for an acute IRF.
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical history of diabetes, and you have with weakness and debility. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do not require physical and occupational therapy but there is no documented need for an intensive
rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standing exercise bicycle.
You asked the Plan to pre-approve these services. You say that you have equilibrium issues and the bike helped you a lot. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a standing exercise bicycle.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the nephrology visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the nephrology visit. You say that you want to be seen where your kidney transplant and blind study were performed. You say these visits are an inexpensive way to prevent more expensive, future medical costs. The Plan denied your request. The Plan says the provider is out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the nephrology visit to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services are not covered.
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 show that you do not suffer from diabetic foot disease and you do not 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 pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), endodontic therapy, anterior tooth (excluding final restoration) (D3310), crown - porcelain fused to predominantly base metal (D2751), and mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214).
You asked the Plan to pre-approve the complete upper and lower dentures, endodontic therapy and crown. You say that you would like the services covered. The Plan denied your request. The Plan says these services are not covered under 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.
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 pre-approve a complete denture - maxillary (D5110), endodontic therapy, anterior tooth (excluding final restoration) (D3310), crown - porcelain fused to predominantly base metal (D2751), and mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) image capture with field of view of both jaws; with or without cranium (D0383).
You asked the Plan to pre-approve a cone beam CT scan. You say that your dentist says this service is required prior to another medically necessary procedure. The Plan denied your request. The Plan says this service is not covered under 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. 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 pre-approve a cone beam computed tomography (CT) image capture with field of view of both jaws; with or without cranium (D0383).