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

We decided that the Plan does not have to pay for the follow-up inpatient consultation (G0407) provided on January 18, 2021.
You asked the Plan to pay for the follow-up inpatient consultation. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare
coverage criteria have been met. We looked at the file and Medicare rules. In this case, there were no medical records provided for the January 18, 2021 date of service. We are unable to verify if Medicare criteria have been met. Therefore, we decided that the Plan does not have to pay for the follow-up inpatient consultation (G0407) provided on January 18, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy.
You asked the Plan to pre-approve physical therapy. You say that the physical therapy you were receiving was improving your shoulder with good results. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the clinical notes do not show loss of function or that ongoing physical therapy is needed.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the need for more shoulder physical therapy has not been established. You do not have significant disability from shoulder pain documented at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency ambulance services (A0246, A0425, 93041) provided on June 25, 2020.
You asked the Plan to waive the copayment for non-emergency ambulance services. You say that you should not be responsible for the charges. The Plan denied your request. The Plan says the copayment was 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 $250 copayment for ambulance services. You have been asked to pay a $250 copayment for non-emergency ambulance services. The services at issue fall within the ambulance services 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 non-emergency ambulance services (A0246, A0425, 93041) provided on June 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an occlusal adjustment (D9951) provided on April 29, 2021.
You asked the Plan to pay for an occlusal adjustment. You say that you want to know why the service was
denied. The Plan denied your request. The Plan says the service at issue is not a covered 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 pay for an
occlusal adjustment (D9951) provided on April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that you need this power wheelchair as the manual wheelchair is not meeting your needs. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary for the safety of your life. The Plan denied your request. The Plan says that therapy can safely be received at a different setting. 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation.
You asked the Plan to pre-approve SI joint radiofrequency ablation. You say that the services are necessary.
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage
criteria have not been met.
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 SI joint radiofrequency ablation. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found this is considered an experimental/investigational procedure because of the
wide variation in efficacy reported in the peer reviewed literature. Therefore, the request is considered 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 SI joint radiofrequency ablation have not been met. Therefore, we decided that
the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the abdominal vessels ultrasound as a screening for 
abdominal aortic aneurysm (AAA) (93978). 
 
You asked the Plan to pre-approve the diagnostic service. You say that you feel that the enrollee really needs 
the ultrasound and would like to appeal. The Plan denied your request. The Plan says this test is not medically 
necessary as the records do that the enrollee is above the Medicare age limit for this test. The enrollee is 82 
years old, and the Medicare age range is 60-75 years old. 
 
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.  The age limit for this test specifically says between 65-75 years old. 
As the enrollee is 82 years old, the Medicare criteria has not been met. Based on this information, we decided 
that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the abdominal vessels ultrasound as a screening for abdominal aortic 
aneurysm (AAA) (93978).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing rendered on May 6, 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 services are not a covered 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. The Plan does not cover periodontal scaling and root planing. 

We looked at the file and the Plan's rules. The services at issue are not covered by your supplemental dental benefit. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing rendered on May 6, 2021.
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 February 10, 2021 to February 18, 2021.

You asked the Plan to pay for home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says a correct claim is needed before payment can be made.

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 "from" date on the RAP do not match the information on the claim form. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from February 10, 2021 to February 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998)
provided on January 29, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that the facility called
the ambulance for the enrollee. The enrollee should not be responsible for the charges. The Plan denied your
request. The Plan says the service at issue is not a covered benefit.

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 January 29, 2021. 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 for ambulance response and treatment, no transport
(A0998) provided on January 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right thyroid radiofrequency ablation.

You asked the Plan to pre-approve right thyroid radiofrequency ablation. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for the requested procedure have not been met.

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 right thyroid radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 75-year-old female with a history of multinodular goiter. In this case, there are no indications for radiofrequency ablation of this nodule in terms of symptoms of thyrotoxicosis or local symptoms in the neck. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of right thyroid radiofrequency ablation have not been met.

Therefore, we decided that the Plan does not have to pre-approve right thyroid radiofrequency ablation.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that you no longer have skilled nursing needs and your functional level has
reached a plateau.

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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.

You asked the Plan to pre-approve Gel-One. You say that the requested Gel-One is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Euflexxa first.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Gel-One. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found based on the documentation provided, the enrollee is noted to have osteoarthritis. A request has been made for Gel-One, a hyaluronic acid injection, to treat the osteoporosis. The health plan requires that other forms of hyaluronic acid be used. There is no evidence that the enrollee is allergic to or intolerant of these other forms of medication. There is no evidence that the enrollee has tried and not responded to these other forms of medication. There is no documentation as to why these other forms of medication would not be expected to be safe and effective for the enrollee. Therefore, the requested Gel-One is not shown to be currently medically necessary and 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 Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 30, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotic items provided on December 16, 2020.

You asked the Plan to pay for orthotic items. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for these items is correct, because the Plan was
unable to discover any evidence of an established relationship between the enrollee and the ordering physician
and the documentation does not support the codes billed.

The Plan must follow Medicare rules. Medicare rules say that proof of delivery is required for billed DMEPOS
items.

We looked at the file and Medicare rules. The documentation submitted does not include valid proof of
delivery for the specific items billed on this claim. Based on this information, we decided that Medicare rules
for coverage of orthotic items have not been met. Therefore, we decided that the Plan does not have to pay for
orthotic items provided on December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental x-rays provided on April 13, 2021.

You asked the Plan to pay for the x-rays. You say that you were lied to by the dental office. The Plan denied your request. The Plan says

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. The file shows that you received 3 intraoral x-rays. The Plan paid for 1 x-ray. Your plan only covers one procedure per calendar year. Based on this information, we decided that the Plan's rules for coverage of the x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the dental x-rays provided on April 13, 2021.

Your complaint about the quality of care at the dental office is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided April 13, 2021.

You asked the Plan to pay for the comprehensive oral exam. You say that you had difficulty finding a new provider during the pandemic and received your 2020 exam from an out-of-network provider. You would like the reconsider coverage for the comprehensive exam that was performed when you switched to a network provider this year. The Plan denied your request. The Plan says you have exceeded frequency limits for this service and therefore it is not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the comprehensive oral exam when the services once every three plan years.

We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam was previously covered on June 3, 2020. Based on this information, we determined that the Plan's frequency limit for the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided April 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ground ambulance transport provided on May 12, 2021.

You asked the Plan to waive the copayment for ground ambulance transport. You say that personal emergency response systems are covered. The Plan denied your request. The Plan says you have been charged 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 $295 copayment for each covered, one-way ambulance trip by ground for ambulance services. Please note that the personal emergency response system is a monthly monitoring service and is separate from the ground ambulance service.

You have been asked to pay $295 copayment for each ground ambulance transport. Ground ambulance transport falls within the Ambulance Services 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 ground ambulance transport provided on May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel represented by code 81455 provided on March 4, 2021.

You asked the Plan to pay for code 81455. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

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. Medicare says that genetic testing submitted under code 81455 will be denied as not medically necessary as it is unlikely to impact therapeutic decision-making in the clinical management of the enrollee. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel represented by code 81455 provided on March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services provided on May 7, 2021 by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says prior
authorization was not obtained as required.
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 file shows that the enrollee received a testosterone injection. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 injection services provided on May 7, 2021 by an out-of-network (OON) provider.