Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurostimulator implantation (63650).
You asked the Plan to pre-approve a neurostimulator implantation. You say that the requested care is a necessity for you. The Plan denied your request. The Plan says criteria for a neurostimulator implantation are not met.
The Plan follows Medicare rules. Medicare rules say that no payment may be made for a neurostimulator implantation or services and supplies related to such implantation, unless all of the conditions listed in the Medicare rules section have been met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a neurostimulator implantation. Our reviewer says that the requested procedure is not medically reasonable or necessary. Our physician reviewer found that the enrollee has chronic low back pain. The enrollee has received epidural steroid injection, radiofrequency ablation of medial branches, and sacroiliac joint injections. There is no documentation of a psychological evaluation and medication trials. The enrollee does not have an evidence based indication for a spinal cord stimulation trial. 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 neurostimulator implantation have not been met. Therefore, we decided that the Plan does not have to pre-approve a neurostimulator implantation (63650).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the motion bed purchased on December 2, 2020.
You asked the Plan to pay for these services. You say that you needed the bed for occipital neuralgia. The Plan denied your request. The Plan says the services are 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 pay for the motion bed purchased on December 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for osseous surgery (D4261) provided on July 30, 2020.
You asked the Plan to pay for the osseous surgery. You say that you had services a month prior from this
provider that were paid, so you do not understand why their services are being denied coverage now. The Plan
denied your request. The Plan says this provider has chosen to opt-out of Medicare, which means that care
received from this provider is not eligible for coverage or reimbursement.
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, services received from a provider who
has chosen not to participate in Medicare are not covered under this benefit. Therefore, we decided that the
Plan does not have to pay for osseous surgery (D4261) provided on July 30, 2020.
Your complaint about possible confusion and misunderstanding due to a previously paid claim is not a valid
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan.
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and bite-wing x-rays provided on October 22, 2020 by an OON provider.

You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and bite-wing x-rays. You say that you were not advised that this provider was OON. The Plan denied your request. The Plan says these services were rendered by an OON provider.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and bite-wing x-rays provided on October 22, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 7, 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 testing is not covered.
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 test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on November 30, 2020.

You asked the Plan to waive the copayment for the ambulance ride. You say that you were told that the ambulance ride was free. You say your husband could have driven you to the other hospital. 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 $385 copayment for each Medicare-covered one-way ground ambulance trip. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $385 copayment for the ambulance ride. 

You have been asked to pay a $374.98 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 the ambulance ride provided on November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transurethral destruction of prostate tissue by radiofrequency generated water vapor thermotherapy for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this request does not meet the requirements for coverage.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's prostate score is 20. The record does not indicate he has had a trial of the required medications for three months. The PDE5 Inhibitors that the enrollee is prescribed are dosed for impotence, not benign prostatic hypertrophy. The record does not indicate that the enrollee is a poor candidate for other treatment modalities. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve transurethral destruction of prostate tissue by radiofrequency generated water vapor thermotherapy for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a lumbar/sacral epidural injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that there has not been at least four weeks of physical therapy since the chronic low back pain and left radiculopathy worsened.

The Plan must follow Medicare rules. Medicare rules say that lumbar/sacral epidural injections are covered for certain indications.

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 injection. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the record indicates that the enrollee has degenerative disc disease without myelopathy and radiulitis. The enrollee has failed several treatments, including exercise and chiropractic treatment. The elements of the local coverage determination are satisfied.

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 injection have been met. Therefore, we decided that the Plan has to pre-approve a lumbar/sacral epidural injection for the enrollee.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for FoundationOne Liquid CDx provided on November 13,
2020, by an OON provider.
You asked the Plan to pay for FoundationOne Liquid CDx. You say that you would like reconsideration
because this testing is medically necessary for members with advanced stage, solid tumor cancers who have
decided to seek further treatment. The Plan denied your request. The Plan says non-urgent services should be
from network providers who are contracted with the member's health plan and listed in the Provider Directory.
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 FoundationOne Liquid CDx provided on
November 13, 2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a hearing aid (V5261) received on January 6, 2021.
You asked the Plan to pay for a hearing aid. You say that you would like the Plan to cover the item. The Plan
denied your request. The Plan says the item at issue is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related
services.
Though a hearing aid may be appropriate in this case, neither Medicare nor the Plan covers or pays for these
types of items and services. Therefore, we decided that the Plan does not have to pay for a hearing aid (V5261)
received on January 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown and core buildup, including any pins when required provided on June 9, 2020.
You asked the Plan to pay for the crown and core buildup. You say that this provider never opted out of Medicare. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective February 21, 2017, to February 21, 2021. The Plan also says that charges incurred by Medicare opt out providers will not be reimbursed.
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 crown and core buildup, including any pins when required provided on June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the eyeglasses provided on
December 3, 2020.

You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan says that the Plan paid the correct amount according to your Plan benefit for vision hardware of up to $100.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services with an allowance of up to $100 every two years. 

We looked at the file and the Plan's rules. The file shows that the Plan paid the correct allowance of $100 for the eyeglasses based on your Plan benefit. Therefore, we decided that the Plan does not have to pay an additional amount for the eyeglasses provided on December 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71045) provided on January 4, 2021.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because the member had multiple exams on the billed date of service. The Plan denied your request. The Plan says CPT code 71045 was denied because it is a column II procedure to the column I procedure 71046 billed by a provider in the same group with the same specialty.
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, we have confirmed that code the chest x-ray has a bundled relationship with code 71046 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71045) provided on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Periodic oral evaluation (D0120) and prophylaxis (D1110) provided February 11, 2020, and December 15, 2020.
You asked the Plan to pay for the oral exam and dental cleaning. You say that you had a service at the same provider in August and it was covered so it does not make sense that these services are not covered. The Plan denied your request. The Plan says this provider has opted out of Medicare and therefore the services are not covered.
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. The Plan covers the oral exam and dental cleaning when the services are provided by a licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. We looked at the file and Medicare rules. The provider who rendered the services has opted out of Medicare. Based on this information, we decided that the Plan's rules for coverage of the oral exam and dental cleaning have not been met. Therefore, we decided that the Plan does not have to pay for Periodic oral evaluation (D0120) and prophylaxis (D1110) provided February 11, 2020, and December 15, 2020.
Your complaint about services rendered by this provider potentially being covered on other occasions is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.

You asked the Plan to pre-approve a stair lift. The Plan denied your request. The Plan says the item is 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. T

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 stair lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator provided on November 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the automatic external defibrillator. You say that you would like the payment reprocessed as in-network. 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 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 automatic external defibrillator provided on November 8, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy (PT).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services. 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 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 therapy of 15 visits 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 for physical therapy, by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. 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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy (PT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on December 11, 2020.
You asked the Plan to pay for the dental services. You say that the enrollee's plan allows for 2 oral exams and 2 prophylaxis per year. You also say that this date of service would have satisfied the 2 per year frequency. The Plan denied your request. The Plan says 1 oral exam is covered per calendar year. The Plan says that 1 prophylaxis is covered per year. The Plan also says that the frequency limits for these services have been exceeded.
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 services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for these services that you received on June 9, 2020. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
November 9, 2020.
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing facility care provided on November 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 26, 2020.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the
services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 October
26, 2020.