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

We decided that the Plan does not have to pre-approve the power seat elevation feature (E2300) and power standing feature (E2301), Led lights and indicators (K0108), Ram Mount phone (K0108), Power wheelchair expandable controller (E2377), Power wheelchair expandable controller harness (E2313), or Power wheelchair electronic connection (E2311).
You asked the Plan to pre-approve a power seat elevation feature (E2300) and power standing feature (E2301), Led lights and indicators (K0108), Ram Mount phone (K0108), Power wheelchair expandable controller (E2377), Power wheelchair expandable controller harness (E2313), and Power wheelchair electronic connection (E2311). You say that the enrollee needs a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says the power seat elevation and standing system are not covered. The upgraded electronics are not medically necessary. The Led lights and phone mount do not serve a medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The Led lights and phone mount do not serve a purpose that is primarily medical in nature. The power seat elevation and power standing features are not covered by Medicare or the Plan. The options come with their own switches, so the upgraded electronics are not medically necessary. Therefore, we decided that the Plan does not have to pre-approve power wheelchair power seat elevation feature (E2300) and power standing feature (E2301), Led lights and indicators (K0108), Ram Mount phone (K0108), Power wheelchair expandable controller (E2377), Power wheelchair expandable controller harness (E2313), or Power wheelchair electronic connection (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on
October 1, 2020.
You asked the Plan to pay for a pneumatic compression device. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pay for a pneumatic compression device (E0676) provided on October 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology exam of tissue provided on July 30, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the pathology exam of tissue. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 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 pathology exam of tissue provided on July 30, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for diagnostic or therapeutic nerve blocks and injections (CPT code 01991) provided to the enrollee on January 8, 2021.
You asked the Plan to pay for the services. You say that the services were necessary. The Plan denied your request. The Plan says this enrollee underwent radiofrequency ablation of the right genicular nerve to address right knee osteoarthritis. The Plan states there is no applicable CMS guidance for the provider and enrollee's geography. The Plan states genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the services have not been met. Since the actual service the anesthesia is not covered by the Plan or Medicare, the anesthesia used during the procedure is also not covered. Anesthesia services associated with a non-covered primary procedure are also not covered. Therefore, we decided that the Plan does not have to pay for anesthesia for diagnostic or therapeutic nerve blocks and injections (CPT code 01991) provided to the enrollee on January 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental implant (D6010), bone replacement graft (D7953), and the unspecified preventive procedure (D1999) provided on August 20, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under your dental policy.
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 services provided are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental implant (D6010), bone replacement graft (D7953), and the unspecified preventive procedure (D1999) provided on August 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay on May 8 to May 13, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you have a lot of health issues and can barely keep afloat with all your medical expenses. The Plan denied your request. The Plan says the correct copayment was applied.

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 $275 copayment for each day of days 1-5 of each admission for inpatient hospital care. 

You have been asked to pay a $1,375, or a $275 copayment for each day of days 1-5, of a 5-day inpatient hospital stay. An inpatient hospital stay falls within the "Inpatient hospital care" 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 an inpatient hospital stay on May 8 to May 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the intraoral-periapical first radiographic image (D0220) and the resin-based composite-two surfaces, posterior (D2392) provided on December 29, 2020.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy or by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to issue reimbursement for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to issue reimbursement for the intraoral-periapical first radiographic image (D0220) and the resin-based composite-two surfaces, posterior (D2392) provided on December 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
October 18, 2020.

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 had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the services provided by an out-of-network provider on October
18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based fillings (D2392, D2394) provided on November 12, 2020.

You asked the Plan to pay for the fillings. You say that the provider told you these fillings would be covered. The Plan denied your request. The Plan says fillings are not covered by your supplemental dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based fillings (D2392, D2394) provided on November 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve angiogram with genicular artery embolization of the knee identified with codes 36245, 36246, 36247, 36248, 75774, 75710, 76377, 76380, 76937, 99152, and 37242.

You asked the Plan to pre-approve angiogram with genicular artery embolization of the knee. 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 a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 37242 is vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms). 

We find that the requested services are not a covered benefit. Review of the file shows that angiogram with genicular artery embolization of the knee consisting of multiple procedure codes (36245, 36246, 36247, 36248, 75774, 75710, 76377, 76380, 76937, 99152, 37242) was requested. The plan has approved code 37242 (vascular embolization and occlusion). The provider's office submitted a pre-service request for multiple codes, many of which are not allowed to be billed together. For right now, the main code will suffice, and are unable to verify which of the multiple codes will apply to the actual procedure. The provider will have a second chance to bill those codes after the service. Based on this information, we decided that Medicare rules for coverage of angiogram with genicular artery embolization of the knee have not been met. Therefore, we decided that the Plan does not have to pre-approve angiogram with genicular artery embolization of the knee identified with codes 36245, 36246, 36247, 36248, 75774, 75710, 76377, 76380, 76937, 99152, and 37242.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electric stair lift (CPT code E1399).
You asked the Plan to pre-approve the electric stair lift. You say that you use your emergency inhaler to get up the steps and still gasp for breath which makes you feel like you are collapsing. You state the electric stair lift is medically necessary. The Plan denied your request. The Plan says an electric stair lift (stair elevator) is non-covered because they are not primarily medical in nature.
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 electric stair lift (CPT code E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device (CPT code L8702), for the enrollee.

You asked the Plan to pre-approve the device. You say that the enrollee suffered a right middle cerebral artery (MCA) territory stroke in April of 2020 resulting in spastic left hemiparesis. You state the enrollee has tried rehab therapy including occupational therapy and static bracing that have not worked. The Plan denied your request. The Plan says very little clinical information was received about the enrollee's illness.

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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found under Medicare guidelines, your request is not medically necessary because the medical records provided for review from the enrollee's treating providers do not document failure of standard modalities and/or devices used in the enrollee's rehabilitation, or if the MyoPro is the only device appropriate for the enrollee. The review has determined that the items/services at issue in this case medically are not reasonable or 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device (CPT code L8702), for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional ten (10) PT visits.

You asked the Plan to pre-approve an additional ten (10) PT visits. The Plan denied your request. The Plan says additional PT is not medically necessary.

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 an additional ten (10) PT 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 that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior extensive therapy for this condition and 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 by or under the supervision of a therapist. The enrollee should be able to transition to an independent home exercise program given his prior 18 sessions of therapy. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. Given the enrollee's history of severe degenerative disc disease and severe central spinal stenosis, sciatica and peripheral polyneuropathy, the documentation does not support that ongoing therapy will be effective for these conditions and enrollee may benefit from a follow up with a spine specialist.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an additional ten (10) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional ten (10) PT visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan provided on February 3, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the duplex scan. You say that you were referred to the wrong doctor. You say your doctor is resubmitting the correct referral request. The Plan denied your request. The Plan says no prior authorization was obtained, and the provider is non-contract
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 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 duplex scan provided on February 3, 2021 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on February 5, 2021.

You asked the Plan to waive the copayment for the laboratory work. You say that the laboratory copayment should be waived as this was part of your routine physical. 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 $10 copayment for other Medicare-covered laboratory tests that are not fecal immunochemical tests (FIT).

You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows laboratory work is not considered a part of the annual physical exam. 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 laboratory work provided on February 5, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for outpatient physician surgery services (CPT code 20610) provided on February 18, 2021, and February 25, 2021.
You asked the Plan to waive the copayment for the services. You say that you have a $0 copayment for injections. You state you were given the injection as outpatient and you were seen by the doctor or given an exam. The Plan denied your request. The Plan says that the services were performed in the office (place of service 11), not the ambulatory surgery center, and are asked to pay a $30 copayment per date of service.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for each Medicare-covered specialist visit (including surgery second opinion, telehealth services, and urgently needed services). The Plan says you must pay a $30 copayment for each Medicare-covered specialist visit. Based on the Plan contract, however, you cannot be asked to pay more than $0 copayment for each Medicare-covered specialist visit (including surgery second opinion, telehealth services, and urgently needed services). Therefore, we decided that the Plan has to waive the copayment for outpatient physician surgery services (CPT code 20610) provided on February 18, 2021, and February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on February 2, 2021.
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says you signed a refraction consent form to have this non-Medicare covered service outside your supplemental benefit through the preferred provider network.
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on February 2, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for endoscopy with biopsy provided on
February 24, 2020.
You asked the Plan to waive the copayment for the surgical services. You say that you have never paid for a
colonoscopy. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020
EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received an endoscopy with biopsy on February 24, 2020. The Medicare-allowed amount for the EKG is less than the set $350 copayment; therefore, you have been asked to pay the lesser amount of $190.03 for the surgical services. Your 2020 EOC states enrollees must pay a $350 per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center. 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 endoscopy with biopsy provided on February 24, 2020.