Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a combination sit to stand frame/table system (E0637).
You asked the Plan to pre-approve a combination sit to stand frame/table system. You say that the records
provided should support the medical necessity of the service in dispute. The Plan denied your request. The Plan
says this item is a convenience item and does not primarily 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. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a combination sit to stand frame/table system (E0637).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic testing received on July 2, 2020.

You asked the Plan to waive the copayment for the diagnostic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.

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 $50 copayment for outpatient diagnostic radiology.

You have been asked to pay a $50 copayment for the diagnostic testing. The diagnostic testing falls within the outpatient diagnostic radiology benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic testing received on July 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 29, 2020.

You asked the Plan to pay for the laboratory services.The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the laboratory services. 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 laboratory services provided on October 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on
January 27, 2021.
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that this was a follow-up to
your mammogram screening, 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 an $80
copayment for diagnostic mammograms.
You have been asked to pay an $80 copayment for a diagnostic mammogram. A diagnostic mammogram falls
within the outpatient diagnostic tests and therapeutic services and supplies 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 diagnostic mammogram provided on January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (root canal treatment) (D3310) for tooth 8.

You asked the Plan to pre-approve endodontic therapy. You say that you need this service to say your tooth, and it is too expensive for you to afford on your own.The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental benefit.

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 endodontic therapy (root canal treatment) (D3310) for tooth 8.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 test provided on July 15, 2020.

You asked the Plan to pay for the COVID-19 test. You say that you have no knowledge of enrollee coverage prior to the specimen's arrival at the laboratory. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the COVID-19 test provided on July 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care after April 17, 2021.

You asked the Plan to pre-approve continued inpatient mental health care. You say that you are still a danger to yourself and need care. The Plan denied your request. The Plan says you are no longer a threat to yourself or others.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 continued inpatient mental health care. Our reviewer says that continued inpatient care is not medically necessary. Our physician reviewer found you do not meet the criteria for continued acute inpatient mental health treatment from April 17, 2021, forward as you are not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and were cooperative and compliant with treatment. You were not showing any aggressive behaviors and did not require treatment for acute threats of safety.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health care after April 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride and complete series of
intraoral x-rays provided on December 15, 2020.
You asked the Plan to pay for the topical application of fluoride and complete series of intraoral x-rays. You
say that you declined getting the fluoride treatment but were still billed for it. The Plan also says that these
services should be covered. The Plan denied your request. The Plan says the topical application of fluoride is
not covered. The Plan also says that your benefits for the complete series of intraoral x-rays 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, topical application of fluoride is not
among those covered under this benefit. The contract says that full mouth or panoramic x-rays are limited to
one procedure every three years. The record shows that you received a panoramic x-ray on December 15, 2020,
and your full mouth or panoramic x-rays benefit has been exhausted. Therefore, we decided that the Plan does
not have to pay for the topical application of fluoride and complete series of intraoral x-rays provided on
December 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on December 12,
2020.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not
urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for a domiciliary, rest home visit provided on December 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Flexitouch pneumatic compression device for the
enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says there has been no trial of the non-segmented device.

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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found based on the medical records provided there is no documentation of a trial and failure of the standard
pump.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Flexitouch pneumatic compression device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88381) provided on October 31, 2019.
You asked the Plan to pay for laboratory services. You say that you did not receive the correct insurance
information. The Plan denied your request. The Plan says this was not filed timely.
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 laboratory services was not filed until December 18, 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 laboratory services (88381) provided on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone growth (osteogenesis) stimulator.
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 bone growth stimulator 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 records show that you have a broken bone in your right ankle. You have a displaced fracture with routine healing. The records do not support that the criteria for coverage of a bone growth stimulator are met, as there is no non-union of a long bone fracture. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a bone growth (osteogenesis) stimulator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve panniculectomy and abdominoplasty procedures.
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 panniculectomy and abdominoplasty are 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 records show that you had a prior abdominoplasty and hernia repair in 2018. The case notes indicate that you are unhappy with the results due to excess bulge and off-center umbilicus. There are no reported symptoms. The records support that the services would be entirely cosmetic in nature and 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve panniculectomy and abdominoplasty procedures.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 test provided on July 21, 2020.

You asked the Plan to pay for the COVID-19 test. You say that you no knowledge of enrollee coverage prior to the specimen's arrival at the laboratory. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the COVID-19 test provided on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hydrotherapy for colon cleansing.

You asked the Plan to pre-approve the colon cleansing. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that there are no conditions for which colonic irrigation is medically indicated and no evidence of therapeutic value. Accordingly, colonic irrigation cannot be considered reasonable and necessary. 

We looked at the file and Medicare rules. The requested colon cleansing is not medically reasonable and necessary per NCD 100.7, and therefore is non-covered. Based on this information, we decided that Medicare rules for coverage of the colon cleansing have not been met. Therefore, we decided that the Plan does not have to pre-approve hydrotherapy for colon cleansing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2740 x4), a maxillary partial denture (D5213), and a mandibular partial denture (D5214).

You asked the Plan to pre-approve crowns, a maxillary partial denture, and a mandibular partial denture. You say that you would like the Plan to pre-approve the services because they need to be replaced. The Plan denied your request. The Plan says the services are a covered benefit, but you have exceeded the frequency limit of one every five years.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of crowns, a maxillary partial denture, and a mandibular partial denture have not been met. Specifically, the record shows that you had exceeded the frequency limit for crowns prior to this service on December 10, 2019. You also had exceeded the frequency limit for a maxillary partial denture and mandibular partial denture prior to this service on January 21, 2020. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740 x4), a maxillary partial denture (D5213), and a mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes a complete oral evaluation, and a complete intraoral series of radiographic images once every three years. You can find this information on pages 4-53 to 4-55 of the Plan's 2020 Evidence of Coverage (EOC).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services (A0431, A0436) provided on November 29, 2020.

You asked the Plan to pay for air ambulance services. You say that this was an emergency. The Plan denied your request. The Plan says air transport was not medically necessary.

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.

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 air ambulance services. Our reviewer says that air ambulance services were not medically necessary in this case. Our physician reviewer found the documentation does not support that the patient's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground posed a threat to the patient's survival or seriously endangered the patient's health.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance services (A0431, A0436) provided on November 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on
November 10, 2020.

You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says the services provided 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 above, are not covered. Cardiovascular disease screening tests are only covered for certain
indications.

The cardiovascular disease screening test at issue in this appeal were requested solely for screening purposes.
While Medicare covers cardiovascular disease screening tests for certain indications, the documentation does
not support that the enrollee met criteria for the services rendered. Therefore, we decided that the Plan does not
have to pay for the cardiovascular risk assessment testing provided on November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on November 11,
2020.
You asked the Plan to waive the copayment for emergency care. You say that you discontinued a medication,
and you feel that this is the reason for your trip to the emergency room. 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 $75
copayment for emergency care.
You have been asked to pay a $75 copayment for emergency care. Emergency care falls within the emergency
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 emergency care provided on
November 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower extremity prosthesis.

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 procedure code L5999 is not covered.

The Plan must follow Medicare rules. The rules say that Code L5999 must not be used to bill for any features or functions included in the socket or addition codes. 

We looked at the file and Medicare rules. Procedure code L5999 cannot be approved, as the item is already covered by the approved codes. 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 lower extremity prosthesis.