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

We decided that the Plan does not have to pay for the dental services provided on November 7, 2019.
You asked the Plan to pay for the dental services. You say that these services are fully covered under your
preventative service. The Plan denied your request. The Plan says that you may pay more when you receive
services out-of-network
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan says that you can get
care from an out-of-network dental provider but you may pay more.
We looked at the file and Medicare rules. The file indicates you went to an out-of-network dentist and the plan
paid up to the maximum benefit amount. You are responsible for any charges over that amount. Based on this
information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore,
we decided that the Plan does not have to pay for the dental services provided on November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 23, 2019 by an out of network (OON) provider.
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 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 for the medical services provided on October 23, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveswitch operated fender lights (K0108).You asked the Plan to pre-approveswitch operated fender lights. You say that the itemsare necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 switch operated fender lights. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found these items and accessories donot improve or allow the safe functioning of the power mobility device. They are therefore convenience items and deemed 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 switch operated fender lights have not been met.Therefore, we decided that the Plan does not have to pre-approveswitch operated fender lights (K0108).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis on December 23, 2019.You asked the Plan to waive the copayment for the arthrocentesis. You say that you would like to appeal the charges for this claim. 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 a $375 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $375 copayment for the arthrocentesis.You have been asked to pay a $235.65 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 arthrocentesis provided on December 23, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care services provided by a provider that does
not participate in Medicare from October 16, 2019 to October 31, 2019.
You asked the Plan to pay for home health care services. You say that you need these services. The Plan denied
your request. The Plan says services from providers that do not participate in Medicare are not covered.
The Plan must follow Medicare rules. Medicare rules say that home health services are covered only when the
home health agency that is providing the services to the beneficiary has in effect a valid agreement to
participate in the Medicare program
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of home health care services have not been met. The provider you received these services from does
not participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for home
health care services provided by a provider that does not participate in Medicare from October 16, 2019 to
October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis LT RT (L1833) and sleeve LT RT (L2397) provided December 16, 2019.
You asked the Plan to pay for the orthoses. You say that please see the medical records which prove the medical necessity of the item and process the claim for payment. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service so that the Medicare coverage criteria has 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 pay for the orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence to support that the provided services were medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s).
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 knee orthosis LT RT (L1833) and sleeve LT RT (L2397) provided December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve the RFA. You say that The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that RFA is covered for the above indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the RFA. Our reviewer says that the requested RFA is not medically reasonable and necessary. Our physician reviewer found that the only received 70% relief of pain from the dual MBBs. The RFA is not medically reasonable or necessary according to the above indications established in the LCD. 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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 20, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered on November 20, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (99334) provided December 20, 2019.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not preauthorized or emergent. There were network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 outpatient mental health services (99334) provided December 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facet joint injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that you feel that this is the best treatment for the enrollee. The Plan denied your request. The Plan says there is evidence of radicular leg pain.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee has radicular leg pain. There are causative reasons for this type of radicular pain, including significant spinal stenosis, a previous compression fracture, and previous lumbar spine surgery. The review has determined that the enrollee does not have the indications for a facet joint injection. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a facet joint injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on November 18, 2019.You asked the Plan to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a necessary service.The Plan denied your request. The Plan says payment for this service is included in the DRG.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on November 18, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carfilzomib and Cyclophosphamide 100mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the use of this drug requires the enrollee has not experienced disease progression while on Kyprolis (carfilzomib) therapy that requires a change in therapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the drug. Our reviewer says that the requested drugs are not medically reasonable or necessary. Our physician reviewer found submitted documentation, Medicare guidelines, and Medicare approved compendia were considered. The enrollee has a medical history significant for multiple myeloma. The enrollee has received several different therapies including a clinical trial with disease progression. Records support a therapy trialed included Kyprolis therapy. Reviewed compendia do not support the use of Carfilzomib and Cyclophosphamide combination therapy for individuals with previous reaction or disease progression with Kyprolis. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Carfilzomib and Cyclophosphamide 100mg for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to approve in-network coverage for skilled nursing facility (SNF) care to be provided by an out of network (OON) provider.
You asked the Plan to approve in-network coverage for SNF care to be provided by an OON provider. You say that the services are medically necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide this care. Therefore, coverage criteria has not been met.
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 approve in-network coverage for 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 approve in-network coverage for these items/services. Therefore, we decided that the Plan does not have to approve in-network coverage for skilled nursing facility (SNF) care to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits (99213) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that you would like to continue to see your current provider since you have an established history with him and have had successful results while under his care. The Plan denied your request. The Plan says there are in-network providers that are able to provide this care. Therefore, coverage criteria has not been met.
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 pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visits (99213) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient visit and an ECG provided on September 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient visit and an ECG. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-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 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 outpatient visit and an ECG provided on September 26, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvelower lip reconstruction.You asked the Planto pre-approvethe surgery. You say that this is medically necessary.The Plandenied your request. The Plansaysyou have not followed the recommendations from your provides to get fitted for a lower denture.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 surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found you have microstomia and ongoing cosmetic deformity. The plastic surgeon would like you to be fit with a lower denture, as this may place the lower lip in a more prominent position to better determine potential revision. As of 3/5/20, you do not have a lower denture which would be expected to place the left lower lip in a better position to help determine potential revision.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 surgery have not been met.Therefore, we decided that the Plandoes not haveto pre-approvelower lip reconstruction.
Appeal type: Surgery
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pre-approve the medical  services  to be provided  by an out  of network  (OON) provider.You asked the  Plan to pre-approve orthopaedic  consultation.  You say  that none  of the  facilities  you  have  asked for  help  have  given  you  any  alternative  option  to total  knee replacement,  but this  doctor is  willing  to take a chance  to help  you  get  healthier.The  Plan  denied  your  request.  The  Plan  says the denial  of  authorization  for this  service  is  correct,  because this  provider  is out-of-network  with  the Plan  and you  can be treated  by an in-network  orthopaedic  surgery  specialist.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 the  medical  services  to be provided  by an out  of network  (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe special pump services rendered on December 7, 2019.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 are not separately payable.The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.Therefore, we decided that the Plan does not have to pay forthe special pump services rendered on December 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after May 15, 2020.You asked the Plan to pre-approve continued SNF care. You say that the enrollee has required ongoing oxygen support with respiratory difficulty.The Plan denied your request. The Plan says the denial of authorization for continued SNF care is correct.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) setting.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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after May 15, 2020.