Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to enrollee on September 19, 2019 by an out of network (OON) provider.You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services.Therefore, we decided that the Plan does not have to pay for the medical services provided to enrollee on September 19, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bike (E1399).
You asked the Plan to pre-approve Myocycle FES bike. You say that the Myocycle is proven to provide
medical benefits to people with lower limb paralysis and is DME that is reasonable and necessary for treating
the enrollee's condition. The Plan denied your request. The Plan says this item is considered not primarily
medical in nature and therefore is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve bike (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea sacroiliac joint injection for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested procedure is supported when you will also be doing an active exercise program.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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, objective findings included a positive FABER test, and also positive stress maneuver test to the right piriformis. In addition, the treating physician noted palpable tenderness over the right SI joint butdid not document any other physical finding consistent with SI joint dysfunction. The requested service is supported if at least three of the following tests are positive -Patrick's test, thigh thrust, SI compression test, Yeoman's test, or Gaenslan's test. The records do not show three or more positive test results. The review has determined that the requested right sacroiliac joint injection is not medically reasonable and 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 injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea sacroiliac joint injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rateforthe periodic oral evaluation (D0120), the periodontal maintenance (D4910), and the bitewing x-rays (D0274) provided on November 21, 2019 by an out of network dentist.You asked the Plan to pay the in network rate forthe dental services. You say that you pay an additional premium for dental coverage for preventive services. You say that only part of the services was covered.  You also say that you feel the plan does not care about your health and well-being.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says it is the enrollee's responsibility to verify the provider's network status prior to receiving the services. The Plan says services that you receive out of network are subject to a higher cost share. The Plan says that you pay 50% for periodic oral evaluations and bitewing x-rays that you receive out of network. The Plan also says that you pay 75% for periodontal maintenance that you receive out of network.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 dental services you receive out of network are subject to a higher cost share. Therefore, we decided that the Plan does not have to pay the in network rate forthe periodic oral evaluation (D0120), the periodontal maintenance (D4910), and the bitewing x-rays (D0274) provided on November 21, 2019 by an out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture(D5213) and a lower partial denture (D5214).
You asked the Plan to pre-approve the dental services. You say that the partials that you received in 2018 do not fit. You say that you are not able to wear them on a regular basis. You say that they are uncomfortable and rub against your gum and the roof of your mouth. You also say that your front teeth have been wearing. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit for dentures has been reached.
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 partial dentures are listed as a covered service, the frequency limit for partial dentures has been reached. The record shows that the Plan paid for partial dentures that you received on September 28, 2018. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture(D5213) and a lower partial denture (D5214).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance response and treatment, no transport (A0998) provided October 1, 2019 to October 11, 2019.You asked the Plan to pay forambulance response and treatment, no transport. You say that you appealing the decision to deny coverage andis requesting coverage of the ambulance fee's as reasonable and necessary chargesThe Plan denied your request. The Plan says ambulance services without transport are not covered.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 1, 2019 to October 11, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forambulance response and treatment, no transport (A0998) provided October 1, 2019 to October 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on December 2, 2019.

You asked the Plan to pay for the dental service. You say that the x-rays should be covered. You say that the provider's office advised that the 12 month waiting period had passed. You also say that the provider's office advised the x-rays would be covered. The Plan denied your request. The Plan says bitewing x-rays are covered once every 12 months. The Plan also says that the frequency limit 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 and bitewing x-rays are listed as a covered service, the frequency limit for bitewing x-rays has been exceeded. The record shows that the Plan paid for this service that you received on December 13, 2018. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on December 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion services provided to the enrollee from November 1, 2019 to November 8, 2019 and billed under code S9328.You asked the Plan to pay forcode S9328. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare guidance says procedure code S9328 has a status code of "I" and isnot payable for Medicare billingpurposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the code billed has a status codeindicator of "I" which that does not allow payment on Medicare claims.Therefore, we decided that the Plan does not have to pay forhome infusion services provided to the enrollee from November 1, 2019 to November 8, 2019 and billed under code S9328.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepower wheelchair upgraded electronics.You asked the Plan to pre-approvethe power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). You say that the enrollee needs the upgraded electronics to control the power options.The Plan denied your request. The Plan says documentation shows the enrollee has adequate strength and function to control the power options using their own switches.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Documentation shows thatupper limb strength and range of motion are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options. Based on this information, we decided that Medicare rules for coverage of the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377) have not been met.Therefore, we decided that the Plan does not have to pre-approvepower wheelchair upgraded electronics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (S9500) provided on February 13, 2019 through February 21, 2019.You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code S9500 has a status code of I which is not valid for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code S9500 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9500 has a status code of I. This means that CPT code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9500) provided on February 13, 2019 through February 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the occlusal guard (D9945).
You asked the Plan to pre-approve the occlusal guard. You say that an occlusal guard/splint is indicated for treatment because the enrollee has muscle and dental pain secondary to grinding and clinching. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit package.
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 pre-approve the occlusal guard (D9945).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on December 4, 2019.
You asked the Plan to waive the copayment for an office visit. You say that these were follow-up visits and you disagree with the charges. 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 $35 copayment for specialist visits. You had an office visit on December 4, 2019 with a specialist. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $35 copayment. You have been asked to pay a $35 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office 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 copayment for an office visit provided on December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the replacement of a broken tooth on an existing partial denture.
You asked the Plan to pre-approve the replacement of a broken tooth. You say that the enrollee likes the fit of his existing partial denture and would like the missing tooth to be fixed. The Plan denied your request. The Plan says this service is not a covered benefit under the enrollee's dental plan.
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 pre-approve the replacement of a broken tooth on an existing partial denture.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay forthe 2 retainer crowns (D6740) and the pontic (D6245) provided on September 27, 2019.You asked the Plan to pay forthe dental services. You say that you were advised your benefits would cover 50%, or up to $1,700, for the bridge. You say that you were told this prior to receiving the bridge.The Plan denied your request. The Plan says that they cover the service with materials that are usual and customary. The Plan also says that porcelain and ceramic are not considered usual and customary materials.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.  follows these rules.The provider is this case is a contract provider. The file does not show that  provided notice that the dental services would not be covered. Under Medicare rules, this means the dental services is considered approved by .Therefore, we decided that the Plan has to pay forthe 2 retainer crowns (D6740) and the pontic (D6245) provided on September 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided out of network on June 14, 2019 at the in-network rate.You asked the Plan to pay foroutof network services at the in-network rate. You say that due to the distance of the provider, this should be covered at the in-networkrate.The Plan says this request has been granted as a onetimecourtesy, however future use of this provider will becharged at the out of network rate per the plan contract agreement.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that if you use out of network providers, the cost share will be higher. The provider in question was not in network. The Plan had network providers who could provide this treatment. The Plan contract is clear that if you use out of network providers the cost will be higher. We found no exception that would require the Plan to pay for these at the in-network rate. Therefore, we decided that the Plan does not have to pay forphysician services provided out of network on June 14, 2019 at the in-network rate.Again, we note the Plan indicates they have granted your request as a onetime courtesy, even though they are not required by Medicare to do so.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe consultation services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethese OON services. You say that you would like the plan to reconsider their denial.The Plan denied your request.The Plan says the requested services can be provided by a network provider.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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe consultation services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says needs can be met at an alternate level of care, such as in a skilled nursing facility.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee'smedical status does not require intensive physician or nursing supervision in an IRF. The enrolleemay benefit from PT and OT but the documentation does not indicate that the enrollee's functional status requires this on an intensive level in an IRF.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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram.You asked the Plan to pre-approve a transthoracic echocardiogram. The Plan denied your request. The Plan says this is not medically necessary.The Plan follows Medicare rules. Medicare rules say that a transthoracic echocardiogram is considered not medically necessary for the above 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 transthoracic echocardiogram. Our reviewer says that a transthoracic echocardiogram is not medically reasonable and necessary. Our physician reviewer found that the enrollee has known heart disease, no reported cardiac symptoms and reduced left ventricular ejection fraction with normal prosthetic aortic valve function on a recent echocardiogram on January 6, 2020. In this circumstance of a recent echocardiogram in a clinically stable patient, the records do not support the medical necessity for a repeat echocardiogram about 3 months after the prior exam. Coverage criteria are not met since coverage limitations include "Routine (yearly) evaluation of a patient with a prosthetic valve in whom there is no suspicion of valvular dysfunction and no change inclinical status, routine (yearly) re-evaluation of patients with heart failure (systolic or diastolic) in whom there is no change in clinical status and routine (yearly) evaluation of cardiomyopathy in a patient with no change in clinical status".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 transthoracic echocardiogram have not been met.Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiogram.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on May 31, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says services must be provided by an in-network provider.
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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on May 31, 2019.