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

We decided that the Plan does not have to pay for the resin-based composite provided on December 23, 2020.
You asked the Plan to pay for the resin-based composite. You say that you feel you should not be held responsible for this service. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has 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, restorations are limited to one procedure per calendar year. The record shows that you received two resin-based composites on December 23, 2020, one of which was covered by the Plan, and your restorations benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite provided on December 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a spinal canal injection provided on
November 9, 2020.
You asked the Plan to waive the copayment for a spinal canal injection. You say that you received the services
at an ambulatory surgical center. The Plan denied your request. The Plan says the claims were processed
correctly, and you are being charged the correct 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 $350
copayment for outpatient surgery, including services provided at hospital outpatient facilities.
The medical records show that you received a spinal canal injection at an outpatient hospital facility, on
November 9, 2020. Therefore, you are responsible to pay the $350 copayment.
You have been asked to pay a $350 copayment for a spinal canal injection. A spinal canal injection falls within
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers 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 a spinal canal injection provided
on November 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cane holder for the power wheelchair.
You asked the Plan to pre-approve a cane holder. The Plan denied your request. The Plan says the item does 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 item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a cane holder for the power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left side facet joint injections 64493, 64494 and 64495.

You asked the Plan to pre-approve the facet joint injections. You say that please see attached clinical
information, including office notes from 1/28/2021. The Plan denied your request. The Plan says this service is
not medically necessary as the enrollee would be exceeding limitations.

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 facet joint injections. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the documentation does not reveal that the patient has had for at least three (3)
months of 50% pain relief and objective functional improvement from prior injections therefore this request is
not medically 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 facet joint injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve left side facet joint injections 64493, 64494 and 64495.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on December 17, 2018.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was
submitted after the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.

The record shows that a claim for the services was not filed until December 11, 2020. This means that more
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that
the Plan does not have to pay for the services provided on December 17, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power operated vehicle (POV).
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 covered.
The Plan must follow Medicare rules. Medicare rules say that Group 2 POVs are denied as not medically necessary. We looked at the file and Medicare rules. The item at issue is a Group 2 POV described by code K0808. This item is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power operated vehicle (POV).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on August 25, 2020.
You asked the Plan to reimburse you for the hearing aids. You say that you were not aware you had to use the Plan's provider. The Plan denied your request. The Plan says coverage for hearing aids is limited to the Plan's hearing aid provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plan's hearing aid provider. We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on August 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest.

You asked the Plan to pre-approve a CT scan. The Plan denied your request. The Plan says the size of the pulmonary nodule was not provided.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CT scan. Our physician reviewer found that the enrollee is an active smoker with a history of pulmonary nodule identified on a chest CT scan 1 year ago. There is no documentation indicating the size of the nodule, and no previous CT report provided for review. The literature states for multiple solid noncalcified nodules with at least one nodule 6 mm or larger in diameter, follow-up is recommended at approximately 3-6 months, followed by an optional second scan at 18-24 months that will depend on estimated risk. The review has determined that the requested CT scan of the chest is not medically necessary or reasonable. 

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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lap sleeve gastrectomy.

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 enrollee does not meet the criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that bariatric surgery is covered for benificiaries with
a BMI of greater than or equal to 35.

We looked at the file and Medicare rules. The record show that the enrollee has a BMI of 33.9. 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 lap sleeve gastrectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist services rendered on January 14, 2020 to November 18, 2020.

You asked the Plan to waive the copayments for these services. You say that you never had a copayment for the services before. The Plan denied your request. The Plan says the copayments were applied correctly.

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 $40 copayment for each covered specialist office visit.

Review of the file shows that you received specialist services for 10 dates of service from January 14, 2020 to November 18, 2020. You have been asked to pay a $40 copayment per visit for these services, for a total of $400. These services fall within the covered specialist office visit 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 copayments for the specialist services rendered on January 14, 2020 to November 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on November
30, 2020.
You asked the Plan to waive the copayment for the laboratory work. You say that the copayment should be
waived because the labs were part of the physical exam. 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 Medicare-covered laboratory tests. This copayment does not apply to blood draws or INR
testing (anti-coagulant testing). You will only pay one copayment per day even if multiple laboratory tests are
performed.
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 the
laboratory work was done in addition to 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 November 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851x2) suspension sleeve (L2397x2) shoulder elbow wrist hand orthosis (L3960) neuromuscular stimulator, electronic shock unit (E0745) and electrical stimulator supplies (A4595) provided June 25, 2020.

You asked the Plan to pay for the orthoses and neuromuscular stimulator and supplies. You say that please take into consideration and process the claim for further payment. The Plan denied your request. The Plan says the plan was unable to discover any evidence of an established relationship between the enrollee and the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the orthoses and neuromuscular stimulator and supplies. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found The available documentation in the case file does not support that the requested lumbar-sacral orthosis, knee orthoses with sleeves, shoulder/arm orthosis and the neuromuscular stimulator was medically reasonable and necessary for the enrollee as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination for the items provided in this case. 

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 orthoses and neuromuscular stimulator and supplies have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851x2) suspension sleeve (L2397x2) shoulder elbow wrist hand orthosis (L3960) neuromuscular stimulator, electronic shock unit (E0745) and electrical stimulator supplies (A4595) provided June 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a methylprednisolone injection.
You asked the Plan to pay for a methylprednisolone injection. The Plan denied your request. The Plan says this is not covered under your Part B plan.
The Plan must follow Medicare rules. The rules 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. Therefore, we decided that the Plan does not have to pay for a methylprednisolone injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided December 8,
2020.

You asked the Plan to pay for the limited oral evaluation. You say that the services were necessary. The Plan
denied your request. The Plan says this service is not covered under your dental 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 pay for the
limited oral evaluation (D0140) provided December 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.

You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.

Benefits for Prolia 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 pre-approve an office visit (99203) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that you would like a second opinion and the network provider is too far away. The Plan denied your request. The Plan says the plan has approved a visit with a network provider for a second opinion.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office visit (99203) to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure and additional intraoral periapical
x-ray provided on November 16, 2020.

You asked the Plan to pay for the preventive procedure and additional intraoral periapical x-ray. You say that
you believe these services should be covered. The Plan denied your request. The Plan says the preventive
procedure is not a covered benefit. The Plan also says that your benefits for the additional intraoral periapical
x-ray have been satisfied and the frequency limitation has 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, unspecified preventive procedure is not
among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure per
calendar year. The record shows that you received a first intraoral periapical x-ray on November 16, 2020,
which was covered by the Plan and your intraoral x-rays benefit has been exhausted. Therefore, we decided
that the Plan does not have to pay for the preventive procedure and additional intraoral periapical x-ray
provided on November 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

We decided that the Plan does not have to pay for an ambulance transport (A0428, A0425) provided October 13, 2020.

You asked the Plan to pay for the ambulance transport. You say that the ambulance transportation was medically necessary. The Plan denied your request. The Plan says coverage criteria was not met.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the ambulance transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found the enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. Transportation could have been provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition.

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 ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for an ambulance transport (A0428, A0425) provided October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 200/100-day supply of diabetic test strips.
You asked the Plan to pre-approve a 200/100-day supply of diabetic test strips for a home blood glucose
monitor. You say that the enrollee is checking levels twice a day. The Plan denied your request. The Plan says
current information indicates the available amount is adequate.
The Plan must follow Medicare rules. Medicare rules say that test strips are available as a recurring 90-day
supply under Part B.
We looked at the file and Medicare rules. Test strips are available as a 180/90-day supply. They are not
available as a 100-day supply and there is no documentation to support a higher utilization supply. Based on
this information, we decided that Medicare rules for coverage of a supply of diabetic test strips for a home
blood glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a
200/100-day supply of diabetic test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. You say that the enrollee has been seeing the provider since an infant. The Plan denied your request. The Plan says the enrollee is able to see a provider within the 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network (OON) provider.