Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from January 25, 2021 to January 27, 2021.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim was submitted with an invalid type of bill. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 25, 2021 to January 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (CPT code L0651) provided to the enrollee on May 12, 2021.
You asked the Plan to pay for the orthosis. You say that the enrollee has lumbosacral radiculopathy due to osteoarthritis of the spine. The Plan denied your request. The Plan says the enrollee did not have a reported injury. The Plan states the enrollee did not have weakness of the back muscles. The Plan states the enrollee did not have any problems moving their neck and low back. There was no evidence to suggest a pinched nerve. The member did not have back surgery.
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 orthosis.
Our physician reviewer found the available documentation in the case file does not support that the requested lumbar-sacral orthosis was ordered to reduce pain by restricting mobility of the trunk, to facilitate healing following an injury to the spine or related soft tissues, to facilitate healing following a surgical procedure on the spine or related soft tissue, or to otherwise support weak spinal muscles and/or a deformed spine. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (CPT code L0651) provided to the enrollee on May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) radiofrequency ablation (RFA) (CPT code 64625), for the enrollee.

You asked the Plan to pre-approve the service. You say that the enrollee continues to have low back pain with intermittent weakness in their legs. You state the enrollee continues to have problems associated with the intense pain. The Plan denied your request. The Plan says the services are considered experimental and investigational.

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 service. Our physician reviewer found the record indicates that the enrollee has low back pain from sacroiliac joint dysfunction. The requested service is excluded from coverage under the criteria. The elements of the coverage criteria are satisfied. The requested service cannot be recommended. 

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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) radiofrequency ablation (RFA) (CPT code 64625), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right L3, L4, L5 medial branch blocks.
You asked the Plan to pre-approve medial branch blocks.. 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 medial branch blocks 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 medial branch blocks. 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's physical exam shows decreased range of motion of the lumbar spine. The enrollee has had chiropractic and physical therapy but the dates, duration and extent of effectiveness is not documented. The enrollee is taking Percocet and non-steroidal anti-inflammatory drugs for pain. There isn't clear documentation of the extent and duration of conservative therapy. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of medial branch blocks. have not been met. Therefore, we decided that the Plan does not have to pre-approve right L3, L4, L5 medial branch blocks.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 8, 2021.
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Review of the file does not support This means that the Guardant360 testing at issue in this appeal 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 Guardant360 testing provided on March 8, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the stress test you had on May 3, 2021.
You asked the Plan to waive the coinsurance for the stress test. You say that because the hospital provider
didn't read the report and your doctor did, you should not have to pay the coinsurance. The Plan denied your
request. The Plan says you were charged this coinsurance 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 20%
coinsurance for diagnostic tests.
You have been asked to pay 20% coinsurance for the stress test. The stress test falls within the diagnostic tests
benefit category. This coinsurance applies regardless of who actually reads the report. 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 coinsurance for the stress test you had on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for fluoroscopic guided steroid injection provided on May 11,
2021 by an out-of-network (OON) provider.
You asked the Plan to pay for an injection. You say that you would like this claim reprocessed and paid. The
Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that there are
in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 fluoroscopic guided steroid injection provided on
May 11, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1852).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the records do not demonstrate recent injury or surgery, or that instability of the knee
was found on physical exam.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found you do not have any instability of your ligaments on exam. There are no updated objective exam findings
provided. Detailed documentation is not evident regarding instability on the knee. There is no indication that a
recent injury or surgery has taken place. In addition, detailed documentation is not evident as to why the
previously utilized knee brace would not be sufficient for use. There is no compelling rationale presented or
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines.
Therefore, the request for knee orthosis (L1852) is not medically 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a knee orthosis (L1852).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance service, basic life support, non-emergency transport (CPT code A0428), for the enrollee.
You asked the Plan to pre-approve the ambulance service. You say that the enrollee has end-stage renal disease on hemodialysis. You state the enrollee has severe weakness, gait disturbance and requires oxygen. You state the enrollee is bed confined and requires and ambulance stretcher to and from the dialysis treatment center. The Plan denied your request. The Plan says based on the enrollee's nephrologist's required quarterly report, this enrollee lives with their daughter and can-do light activity. The Plan states the enrollee uses a geriatric wheelchair for ambulation, the enrollee is not bed-bound and can be transported by alternate means of transportation such as a wheelchair vain.
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 pre-approve the ambulance service. Our physician reviewer found the documentation does not support that using a stretcher van would be contraindicated for this non-emergent transport. The documentation does not support that the enrollee requires special equipment or expertise as this is a non-emergent transport and the enrollee is stable. The documentation does not support that the ambulance services for this enrollee are 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 ambulance service have not been met. Therefore, we decided that the Plan does not have to pre-approve ambulance service, basic life support, non-emergency transport (CPT code A0428), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on April 26, 2021.
You asked the Plan to pay for the eye refraction. You say that this service was necessary for your upcoming
cataract surgery. The Plan denied your request. The Plan says this refraction was provided as part of a medical
exam and not as part of a routine eye exam received from a provider in the routine vision network. Medicare
does not cover eye refractions for medical or routine purposes, and the rules for coverage of a routine refraction
have not been met in this case. Therefore, payment is denied for this service.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers eye refractions when they are provided as part of a routine (non-medical) eye exam
being performed by a provider in the Plan's specified routine vision network.
We looked at the file and the Plan's rules. The eye refraction was performed as part of a medical exam and was
received from a provider who participates in the Plan's medical network but not the routine vision network.
Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been
met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on April
26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for lens upgrades provided on April 3, 2021.
You asked the Plan to pay for the upgrades. You say that the rejected services are listed on your eligibility list. The Plan denied your request. The Plan says basic routine vision hardware is covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that you received lens enhancements, including anti-reflective coating, ultraviolet lens, and tint. Your plan only covers basic lenses. The records show you received a discount on your enhancements, as per your benefits and eligibility list. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for lens upgrades provided on April 3, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine vision services provided on May 4, 2021.
You asked the Plan to pay for the services provided. You say that your provider overcharged for the services.
The Plan denied your request. The Plan says the claim processed correctly.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. You were not charged for the eye exam you received. The Plan paid $200 toward your frame and lens benefit. You pay any amount over $200. Based on this information, we decided that the Plan's rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the routine vision services provided on May 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there is a continued requirement and need to stay in intensive rehabilitation.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled therapy service needs. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for visits you had with a plastic surgeon
related to cyst removal from January 4, 2021, to May 4, 2021.
You asked the Plan to waive the copayments for the plastic surgery visits. You say that you had to return to this
provider multiple times because the cyst was not removed completely the first time. You do not think you
should have to pay copayments for each visit. The Plan denied your request. The Plan says you were charged
these copayments 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 $35
copayment for visits with a specialist. You have been asked to pay a $35 copayment for each of the plastic surgery visits. The plastic surgery visits
fall within the visits with a specialist benefit category. These copayments apply regardless of the reason for the
visits. 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 visits you had with a plastic surgeon related to
cyst removal from January 4, 2021, to May 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on 
March 26, 2021.

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 claim was not billed with an appropriate diagnosis code.

The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise 
diagnosis code.

We looked at the file and Medicare rules. The file shows that the claim was not billed with an 
appropriate primary diagnosis code. 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 pay for the 
computed tomography (CT) scan rendered on March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network
(OON) provider on February 10, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for
this service. Therefore, we decided that the Plan does not have to pay for the office visit (99203) rendered by
the out-of-network (OON) provider on February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) and the additional of a tooth to a
partial denture (D5650) provided on January 25, 2021.
You asked the Plan to pay for the dental services. You say that extractions are supposed to be covered at 50%.
You say that the Plan only paid $38.25 because the provider was not in network. You also say that every
provider in the book said they did not take your plan or was a pediatric dentist. The Plan denied your request.
The Plan says 2 extractions are covered per calendar year. The Plan says you pay 55% for extractions that you
receive out of network. The Plan says the coinsurance level will apply to the average negotiated in network fee
schedule (INFS) in the member's area. The Plan also says that the enrollee is responsible for the difference
between the INFS and dentists' charged fees when visiting an out of network dentist.
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 extraction is listed as covered,
there is a 55% coinsurance that applies to this service when it is performed out of network. Out of network
providers may bill you for the amount greater than the Plan pays. This is a contractual obligation you agreed to
when you enrolled in the Plan's dental coverage. Additionally, the addition of a tooth to a partial denture is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
extraction (D7140) and the additional of a tooth to a partial denture (D5650) provided on January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor provided on April 13, 2021.

You asked the Plan to pay for the provided services. The Plan denied your request. The Plan says the documentation did not indicate the provider discussed the need for the billed code.

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 a valid physician order which supports medical necessity for the supplies provided in this case. 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 continuous glucose monitor provided on April 13, 2021.