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

We decided that the Plan does not have to pay for the extraction (D7210) and the personal protective equipment (PPE) (D1999) provided on December 4, 2020.
You asked the Plan to pay for the PPE. You say that these services should be covered. The Plan denied your request. The Plan says PPE is not listed as a covered service.
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 PPE is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction (D7210) and the personal protective equipment (PPE) (D1999) provided on December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoster vaccine (90755) and the administration of the vaccine (90471) provided on January 12, 2021.
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 this vaccine is not a covered benefit under your contractual policy.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the Zoster vaccine (90755) and the administration of the vaccine (90471) provided on January 12, 2021.
Benefits for this vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit provided on
January 19, 2021.
You asked the Plan to waive the copayment for the telehealth visits. The Plan denied your request. The Plan
says you must pay $25 for each individual or group therapy visit for Medicare-covered outpatient mental health
services.
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 $25
copayment for outpatient mental health care.
You have been asked to pay $25 copayment for the telehealth visits. The telehealth visits falls within the
outpatient mental health 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 telehealth
visit provided on January 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0428, A0425) provided on November 12, 2020.
You asked the Plan to pay for ambulance services. You say that these services are supported by the medical records. The Plan denied your request. The Plan says these services are not separately payable from the enrollee's inpatient stay.
The Plan must follow Medicare rules. Medicare rules say that all items and nonphysician services, including transportation, furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. We looked at the file and Medicare rules. The record shows that the enrollee was an inpatient from November 11, 2020 to November 14, 2020. As the transportation at issue was furnished during this stay, it must be furnished directly by the hospital or billed through the hospital under arrangements. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0428, A0425) provided on November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the exercise equipment (A9300) received August 31, 2020.
You asked the Plan to pay for the exercise equipment. You say that you needed the exercise equipment because your gym was closed due to the pandemic. The Plan denied your request. The Plan says exercise equipment purchases made prior to October 1, 2020 do not qualify for reimbursement.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. As part of the Temporary COIVD-19 Fitness Equipment Reimbursement Policy, the Plan covers exercise equipment only when purchased between October 1 and December 31, 2020. The Plan's rules for coverage of gym benefits have not been met because the exercise equipment was purchased before the benefit effective date of October 1, 2020. Therefore, we decided that the Plan does not have to pay for the exercise equipment (A9300) received August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facet injection.
You asked the Plan to pre-approve a facet injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that facet injections are only 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 a facet injection. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain. The enrollee has had epidural steroid injections, chiropractic therapy, physical therapy and transcutaneous electrical nerve stimulation (TENS) trial. The enrollee takes Tramadol for pain. The enrollee's Magnetic resonance imaging (MRI) shows prior placement of pedicle screws at L4 and L5 and posterior fusion at L5-S1. The enrollee has multiple level disc bulges and foraminal narrowing at multiple sites as well as facet arthropathy. The enrollee has had multiple pain generators that have not been addressed. This does not meet the criteria of the LCD. Therefore, the requested services are not medically necessary.
Review of the file shows that the Plan uses Local Coverage Determination (LCD) L35996 to support their denial. However, LCD L35996 is retired; therefore, we cannot use LCD L35996 to substantiate our decision. 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 facet injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a facet injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 the enrollee was admitted for hip surgery to remove ectopic bone formed after a hip replacement surgery. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. 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 acute inpatient rehabilitation facility (IRF) admission and services.
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 you would like the plan to reconsider
their denial The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee was admitted to the acute inpatient setting for the treatment of acute
hypoxic respiratory failure due to COVID pneumonia. There is no documentation provided necessitating
admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The
enrollee does not require services at the LTACH that are not available at the acute care hospital where the
enrollee is 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.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan of the heart and arteries and
self-administered drugs provided on January 4, 2021.
You asked the Plan to waive the copayment for the CT scan of the heart and arteries and self-administered
drugs. You say that you would like to appeal the amount you were charged. The Plan denied your request. The
Plan says the copayment amount you are being charged is correct. The Plan also says that self-administered
drugs are not covered.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The rules also say that Medicare Part B generally does not pay for
self-administered drugs. The self-administered drugs requested here are not among the types which are covered
by Medicare Part B. Your contract with the Plan clearly says that you must pay a $250 copayment for
Outpatient Diagnostic Tests and Therapeutic Services and Supplies. You are responsible for the total allowed
amount of $190.10 for the CT scan because this amount is less than the $250. You are also responsible for the
additional $3.50 for the self-administered drugs, as self-administered drugs are not covered in an outpatient
setting.
You have been asked to pay a $193.60 copayment for the CT scan of the heart and arteries and selfadministered
drugs. CT scan of the heart and arteries falls within the Outpatient Diagnostic Tests and
Therapeutic Services and Supplies benefit category. Self-administered drugs fall within the Outpatient Hospital
Services. 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 CT scan of the heart and arteries and selfadministered
drugs provided on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for a telehealth office visit received on January
20, 2021.

You asked the Plan to waive the co-payment for the visit. You say that there should not be a co-payment for just
asking a provider a question over the phone. The Plan denied your request. The Plan says the co-payment was
applied correctly according to your benefits and the services rendered.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10
co-payment for PCP visits.

You have been asked to pay a $10 co-payment for the visit. The visit falls within the PCP visits 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 co-payment for a telehealth office visit received on January 20,
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stretta procedure.

You asked the Plan to pre-approve Stretta procedure. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that the Stretta procedure is only 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 Stretta procedure. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has gastroesophageal reflux disease (GERD). The safety and long-term efficacy of surgical augmentation of the lower esophageal sphincter is uncertain in Appellant's setting of a "very large hiatal hernia", ongoing dysphagia due to esophageal dysmotility, and underlying Barrett's esophagus. As such, application of the Stretta procedure for Appellant is neither medically appropriate nor 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 Stretta procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve Stretta procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the interrogation device evaluation provided on December 24, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the interrogation device evaluation. You say that the service is 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 an interrogation device evaluation provided on December 24, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) of heart with evaluation of coronary calcium.

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. Medicare rules say that a heart CT with calcium scoring is covered when specific criteria are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has hypertension and dyslipidemia. The records indicate that she is asymptomatic and the requested test is being used for screening purposes. Medicare does not cover this test for screening purposes; therefore, the services are not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) of heart with evaluation of coronary calcium.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fillings (D2392, D2391) provided on February 15, 2021.

You asked the Plan to pay for the fillings. You say that you only had one filling and the plan covers one filling per year in full. The Plan denied your request. The Plan says you had three fillings on the date in question, for teeth #13, #20 and #21. Two fillings can be covered per calendar year and will require 50% coinsurance. Your benefit and coinsurance have been applied correctly.

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 can cover up to two restorations (fillings) per calendar year. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% coinsurance for each covered filling procedure provided in-network.

You have been asked to pay 50% coinsurance for two fillings. You received fillings on two surfaces of teeth #13 and #20. The Plan is covering these two fillings, but this service requires you to pay 50% coinsurance. The provider charged $188 for each of these fillings. However, the Plan's allowed amount for a filling on two surfaces (D2392) is $124. You do not need to worry about this difference in cost, as this difference is negotiated by the Plan for covered services provided in-network. You are only responsible for 50% coinsurance of the Plan's allowed amount, which means that you must pay $62 for each of the two covered fillings ($124 x 50% coinsurance = $62).

This means that you have been asked to pay the correct amount for the covered fillings based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.

Though the Plan offers a dental benefit in excess of Medicare coverage, the third filling you received (one surface (D2391) on tooth #21) exceeds the number of restorations covered under this benefit per year. The full cost of the third filling is your responsibility. Therefore, we decided that the Plan does not have to pay more or waive the coinsurance for the fillings (D2392, D2391) provided on February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided
December 28, 2020.

You asked the Plan to pay for the therapeutic continuous glucose monitor. You say that the item provided was
medically necessary. The Plan denied your request. The Plan says the coverage criteria have not been met.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.

The record does not contain relevant medical records which support medical necessity for the supplies provided
in this case. In this case, there are no medical records or chart notes detailing the enrollee's medical condition.
The record shows that the Plan made several attempts to obtain the necessary documentation without success.
Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor
provided December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on February 25, 2020.

You asked the Plan to pay for office visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan, authorization was not obtained, and this service was not emergent in nature.

Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.

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 office visit. Our reviewer says that this service does not meet the Medicare criteria for urgent out-of-area care. Our physician reviewer found this was an entirely elective procedure for chronic low back pain. The enrollee could have foreseen requiring this service prior to leaving the Plan's service area. The records do not indicate that this service was medically necessary. It would have been medically reasonable to delay the service until the enrollee's returned to the Plan's service area or up to 6 months.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit provided on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies for a therapeutic CGM (K0553) provided on
December 17, 2020.

You asked the Plan to pay for CGM supplies. You say that the requested items are a medical necessity for the
enrollee. The Plan denied your request. The Plan says rules for CGM supplies have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day nor use insulin with at least three daily injections. Based on this
information, we decided that Medicare rules for coverage of CGM supplies have not been met. Therefore, we
decided that the Plan does not have to pay for supplies for a therapeutic CGM (K0553) provided on December
17, 2020.