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

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral 
periapical x-ray.

You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray.
You say that you would like these services to be covered. The Plan denied your request. The Plan says these
services are 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
problem focused limited oral evaluation and first intraoral periapical x-ray.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided by an OON provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that your doctors were the only providers who were able to treat the enrollee due to COVID-19. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that prior authorization was not obtained.

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 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 the subsequent nursing facility care provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the group 3 heavy duty power wheelchair (K0858).

You asked the Plan to pre-approve the power wheelchair. You say that you would like reconsideration because your current chair does not work well and does not have power tilt/recline. The Plan denied your request. The Plan says the notes do not show that you require power tilt/recline.

The Plan follows Medicare rules. Medicare rules say that a power seating system 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 the power wheelchair. Our reviewer says that you do not require the power options requested with a K0858, group 3 power wheelchair with Single Power Option. Our physician reviewer found you do not have a need for a ventilator or a power tilt and recline. The documentation does not reveal that you are at high risk for development of a pressure ulcer. There is no evidence of spasticity on a physical exam and there is no evidence of intermittent catheterization.

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 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve the group 3 heavy duty power wheelchair (K0858).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy services rendered on September 1, 2020.
You asked the Plan to waive the copayment for these services. You say that you disagree with 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 $35 copayment per Medicare-covered visit for physical therapy. You have been asked to pay a $35 copayment per Medicare-covered visit for these services. these services falls within the physical therapy 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 physical therapy services rendered on September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.

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 physician's 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 physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the outpatient surgery.

You asked the Plan to waive the deductible for the outpatient surgery. You say that you should have been told beforehand that the in-network terms were not met. The Plan denied your request. The Plan says you were charged the deductible correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1000 deductible for some covered services.

The item or service you asked the Plan to waive the deductible for falls within the deductible covered services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible for some services. This cost sharing is a contractual obligation that had not been met at the time the outpatient surgery was received. Therefore, we decided that the Plan does not have to waive the deductible for the outpatient surgery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services were not urgent, emergent or authorized and are available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 the drug testing services provided on January 28, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 23, 2020.
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 there is no physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.
The file does not contain documentation of an established relationship between the enrollee and the ordering
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services
rendered on July 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cosentyx auto-injectors.
You asked the Plan to pre-approve Cosentyx pens (J3590). You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cosentyx auto-injectors.
Benefits for Cosentyx pens (J3590) may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the physical therapy services.

You asked the Plan to reimburse you for the services provided. You say that you thought the billed amount would be entirely covered. The Plan denied your request. The Plan says the allowed amount is less than the copay.

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 copay for out-of-network outpatient rehab services.

Your traditional contractual obligation for this service is a copayment of $35 and the health Plan would pay the remaining balance. However, since the service in of itself resulted in a Medicare allowed amount of $30.22, that is your only financial requirement. The Plan is not required to reimburse any portion of this because you are not being charged any amount over the contractual copayment of $35. The services fall within the outpatient rehab 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 reimburse you for the physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an otolaryngologist visit (99204) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve an OON otolaryngologist visit. You say that the enrollee needs prompt treatment. The Plan denied your request. The Plan says this service is available in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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-approve an otolaryngologist visit (99204) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthopedic mattress (E1399).
You asked the Plan to pre-approve an orthopedic mattress. You say that the member needs this mattress as they need to change positions while sleeping. The Plan denied your request. The Plan says this is not a covered service by the Plan or 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 an orthopedic mattress (E1399).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lumbar spinal fusion surgery.

You asked the Plan to pre-approve the lumbar spinal fusion surgery. You say that this surgery is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested surgery is not medically necessary and reasonable.

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 lumbar spinal fusion surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not show any evidence of spinal instability. In addition, there is no documentation of a recent 6-week trial and failure of physical therapy for back pain.

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 lumbar spinal fusion surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the lumbar spinal fusion surgery.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scans of the thorax (71260) and abdomen and pelvis (74177).
You asked the Plan to pre-approve CT scans of the thorax, abdomen, and pelvis. You say that this is necessary due to the enrollee's weight loss. The Plan denied your request. The Plan says CT scans are not indicated.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve CT scans of the thorax, abdomen, and pelvis. Our reviewer says that the requested CT scans are not medically necessary at this time. Our physician reviewer found per the reviewed documentation, in June 2020 the member weighed 135 pounds. Following knee surgery in October 2020, the member dropped 10 pounds in the first four weeks of post-recovery. In November 2020 the member weighed 122 pounds. In December he weighed 124 pounds and in January 2021 he weighed 125 pounds. There is no documentation of abdominal pain or discomfort. There is no documentation of elimination changes. There is no clinical rationale for the requested CT scans. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scans of the thorax, abdomen, and pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scans of the thorax (71260) and abdomen and pelvis (74177).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing services (D4341 x3, D4342).
You asked the Plan to pre-approve periodontal scaling and root planing services. You say that you wanted to get a checkup but were refused. The Plan denied your request. The Plan says these 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. 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 periodontal scaling and root planing services (D4341 x3, D4342).
Your complaint about potentially being refused a checkup 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the repairs for a power wheelchair.
You asked the Plan to pre-approve the repairs for a power wheelchair. You say that you understand that repair is not covered when due to neglect but would like this covered. The Plan denied your request. The Plan says there is no coverage for durable medical equipment when the damage is due to neglect.
The Plan must follow Medicare rules. Medicare rules say that no coverage is provided for repairs when culpable neglect is responsible for the damage. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the repairs for a power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve the repairs for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an intraoral periapical radiographic image (D0220) provided on September 12, 2020.
You asked the Plan to pay for a limited oral evaluation and an intraoral periapical radiographic image. You say that you were unable to find a network provider that was open and therefore, your only option was an emergency dental care facility. The Plan denied your request. The Plan says the services are not a covered benefit as they were rendered by a non-participating provider.
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. There were no medical records received from the non-contracted provider in this case. Without medical records, we cannot confirm if the limited oral evaluation and imaging services at issue were provided incident to and as an integral part of the emergency tooth extraction. Therefore,
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an intraoral periapical radiographic image (D0220) provided on September 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical management of small bowel obstruction. Post-operative complications included respiratory failure. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services with dental code D2950 on tooth # 2.

You asked the Plan to pre-approve dental code D2950. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental code D2950 is not covered under 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 dental services with dental code D2950 on tooth # 2.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G2024, U0003).

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

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 codes G2024, & U0003 are not supported in the medical record. Specifically, no lab results were provided and there is no evidence of a relationship between the ordering physician and the patient. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G2024, U0003).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab testing (81479, 81302, 81408, 81404, 81406, 81330, 81345, 81407, 81405).

You asked the Plan to pay for the lab testing. You say that the services The Plan denied your request. The Plan says the service at issue is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.

We looked at the file and Medicare rules. The cardiovascular risk assessment panel is not a covered service. Based on this information, we decided that Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not have to pay for lab testing (81479, 81302, 81408, 81404, 81406, 81330, 81345, 81407, 81405).