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

We decided that the Plan does not have to pay for the additional periapical x-ray (D0230), the adjunctive pre-diagnostic test (D0431), nutritional counseling for control of dental disease (D1310), and oral hygiene instructions (D1330) provided on November 12, 2019.
You asked the Plan to pay for the additional periapical x-ray, the adjunctive pre-diagnostic test, nutritional counseling, and oral hygiene instructions. You say that you saw the dentist for a routine cleaning and fluoride which your dental plan covers at 100%. You say that you were advised the x-rays were part of the routine cleaning procedure. You also say that you should be reimbursed for $76 since the cleaning and fluoride should have been covered at 100%. The Plan denied your request. The Plan says 1 set of periapical x-rays are covered per calendar year. The Plan also says that the adjunctive pre-diagnostic test, nutritional counseling, and oral hygiene instruction are not listed as covered services.
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 periapical x-rays are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for the initial periapical x-ray that you received on November 12, 2019. The Evidence of Coverage does not list adjunctive pre-diagnostic test, nutritional counseling, and oral hygiene instruction as covered services. Therefore, we decided that the Plan does not have to pay for the additional periapical x-ray (D0230), the adjunctive pre-diagnostic test (D0431), nutritional counseling for control of dental disease (D1310), and oral hygiene instructions (D1330) provided on November 12, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room Visit provided December 1, 2019.
You asked the Plan to waive the copayment for the Emergency Room Visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 $120 copayment for Emergency Care. You have been asked to pay a $120 copayment for the Emergency Room Visit. The Emergency Room Visit 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 an Emergency Room Visit provided December 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee on May 6, 2019 to July 18, 2019.
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 covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and 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 home infusion therapy rendered on May 6, 2019 to July 18, 2019.
Benefits for these services 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive hearing exam (92557) and digital hearing aids (V5261) provided September 18, 2019.
You asked the Plan to pay for the hearing exam and hearing aids. You say that you went to this provider to get hearing aids and the doctor thought the services would be covered by your insurance. The Plan denied your request. The Plan says enrollee's must receive their hearing services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by a network provider. A prior authorization is required if you are seeking non-emergency care with an out-of-network provider. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing exam and hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for comprehensive hearing exam (92557) and digital hearing aids (V5261) provided September 18, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health nursing services.
You asked the Plan to pre-approve home health services. You say that you are a fall risk. The Plan denied your request. The Plan says you are not homebound.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our physician reviewer found that the documentation does not reveal that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary. The documentation does not reveal evidence of skilled nursing needs such as complex wound care or new enteral feeding. The documentation does not support that you are homebound. Therefore, the requested services are not medically reasonable and necessary 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health nursing services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a right wrist orthosis (L3916-RT), a left wrist orthosis (L3916-LT), and a cervical collar (L0180) provided to the enrollee on September 26, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the encounter appears to be a Telehealth service encounter however Telehealth guidelines have not been 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 pay for the orthoses. Our reviewer says that the documentation does not support that the durable medical equipment is medically necessary for this enrollee. Our physician reviewer found the enrollee's chief complaint was left wrist pain, right wrist pain, and neck pain, documented in three separate notes on the same date of service. The documentation in the case file does not support that the requested cervical collar and bilateral wrist orthoses were medically reasonable and necessary for the enrollee in this case, according to the criteria established by the SSA and CFR. An appropriate physical examination of the wrists, hands and neck would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the cervical collar and bilateral wrist
orthoses were medically reasonable and necessary in this case, as there is no documentation of a credible physical examination of the wrists, hands and 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 the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for a right wrist orthosis (L3916-RT), a left wrist orthosis (L3916-LT), and a cervical collar (L0180) provided to the enrollee on September 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says complex wound care is not needed.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with ventilator management and weaning, tracheostomy care, intravenous antibiotics, surveillance laboratory studies, tube feeding, wound care and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an echocardiography provided on June 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an echocardiography. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 has network providers available who can provide 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 an echocardiography provided on June 18, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says necessary services can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our physician reviewer found that the enrollee was admitted to an acute hospital with sepsis due to a surgical wound infection after lumbar spine surgery. She has been treated in the hospital with vancomycin and meropenem. She is weak, deconditioned, and in need of further rehabilitation with physical and occupational therapy. The acute care hospital is able to provide all of the services the enrollee requires. The enrollee is receiving necessary services and is at an appropriate level of care in the acute care hospital. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic sock
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied your request. The Plan says the requesting provider did not provide sufficient clinical information to determine medical necessity.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve a prosthetic sock
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are 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 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 services are not medically necessary. Our physician reviewer found the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on March 15, 2020 for failure of a deep brain stimulator. She underwent battery replacement of the deep brain stimulator on March 16, 2020 without complication. The physician noted on March 21, 2020 that she is now at her baseline. She has no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit and participate in additional therapy but is near baseline and does not require an intensive rehabilitation facility therapy program 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in bathtub.
You asked the Plan to pre-approve a walk-in bathtub. You say that because of a medical condition you are unable to get out of the bathtub and a walk-in tub will reduce the pain you are in. The Plan denied your request. The Plan says a walk-in bathtub is not considered to be durable medical equipment per Medicare Guidelines.
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. Medicare does not cover home modifications. Therefore, we decided that the Plan does not have to pre-approve a walk-in bathtub.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair of a fluid leak or pseudomeningocele (63709) provided on October 17, 2019.
You asked the Plan to pay for the repair of a fluid leak or pseudomeningocele. You say that this code is not supported. The Plan denied your request. The Plan says this should be paid.
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 asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the repair of a fluid leak or pseudomeningocele. Our reviewer says that the billing of CPT 63709 is not supported. Our physician reviewer found no medical records were submitted for the date of service at issue, therefore, this service cannot be verified. 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 repair of a fluid leak or pseudomeningocele have not been met. Therefore, we decided that the Plan does not have to pay for the repair of a fluid leak or pseudomeningocele (63709) provided on October 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea crown for tooth #5.You asked the Plan to pre-approvethe crown. You say that you were informed that you have $2,500 in dental benefit coverage with the Plan.The Plan denied your request. The Plan says this service 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 pre-approvea crown for tooth #5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea dental core buildups.You asked the Plan to pre-approvethe core buildup. You say that you are in pain.The Plan denied your request. The Plan says the service is non-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.Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea dental core buildups.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 26, 2019 to the enrollee by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The 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. 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 forthe medical services provided on June 26, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forlab services provided to the enrollee on October 30, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysMedicare says tests with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.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 pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found there is limited documentation provided -only a lab result. No provider records have been submitted for review. Therefore, there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forlab services provided to the enrollee on October 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe lumbar vertiflex interspinous spacer for the enrollee.You asked the Planto pre-approvethe spacer. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical studies have not proven that the device is helpful for treatment of the health problem.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 spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer remains experimental for use in surgery. More research is needed.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 spacer have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe lumbar vertiflex interspinous spacer for the enrollee.