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

We decided that the Plan does not have to pay for the office visit (99202), therapeutic exercises (97110), and the manual therapy (97140) provided by physician from September 9, 2019 to October 23, 2019.You asked the Plan to pay for these services.You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the office visit (99202), therapeutic exercises (97110), and the manual therapy (97140) provided September 9, 2019 to October 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for code 88312.
You asked the Plan to pay for podiatry services provided to the enrollee. You say that this claim should be paid. The Plan denied your request. The Plan says while a portion of this claim was paid, code 88312 (4 Units) remains not supported. The Plan stated that the documentation submitted did not include documentation of a special stain including interpretation and report; Group I for microorganisms (4 Units). The Plan states the billed service cannot be verified. The Plan states that multiple attempts were made to contact the provider for additional information
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, insufficient medical records were submitted to support the billing of code 88312. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on October 18, 2019 and billed under 88312.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on November 18, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is a covered benefit; however, you have exceeded your frequency limitation allowable.
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 case file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the periodic oral evaluation have not been met. Specifically, you have exceeded the frequency limitation allowable for this service as you previously received a periodic oral evaluation (D0120) on May 14, 2019 and a limited oral evaluation (D0140) on September 30, 2019. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a cystourethroscopy (52265) provided on September 23, 2019.
You asked the Plan to pay for a cystourethroscopy. You say that the documentation supports this code. The Plan denied your request. The Plan says this code is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 52265 is cystourethroscopy, with dilation of bladder for interstitial cystitis; local anesthesia. 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 a cystourethroscopy. Our reviewer says that CPT 52265 is not supported by the records. Our physician reviewer found the medical records submitted for Septermber 23, 2019 does not include an operative note that documents a Cystourethroscopy, with dilation of bladder for interstitial cystitis; local anesthesia, 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 a cystourethroscopy have not been met. Therefore, we decided that the Plan does not have to pay for a cystourethroscopy (52265) provided on September 23, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 18, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says
the enrollee must receive care from in-network providers with the exception of emergency or urgent care,
dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network
provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for subsequent nursing facility care you provided on April 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the binocular microscopy provided on October 11, 2019 and spirometry provided on October 22, 2019.
You asked the Plan to waive the copayment for the binocular microscopy and spirometry. You say that you were charged for the doctor looking in your ear. You say that you should not be liable. The Plan denied your request. The Plan says the copayments 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 $30 copayment for diagnostic procedures and tests at an in-network specialist's office. You have been asked to pay a $30 copayment for the binocular microscopy and a $30 copayment for the spirometry. The binocular microscopy and spirometry fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 binocular microscopy provided on October 11, 2019 and spirometry provided on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and laboratory services provided on November 26, 2019.
You asked the Plan to waive the copayment for the office visit and laboratory services. You say that you went for a blood pressure check and the conversation lead to diabetes. You say that if the coding is incorrect it should be changed. The Plan denied your request. The Plan says the copayments 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 $20 for each Medicare-covered visit with an in-network PCP and $35 per day, per provider, for in-network, Medicare-covered lab services. You have been asked to pay a total of $30.79 for the office visit and laboratory services.
The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that hypertension, diabetes and laboratory services were addressed during the office visit. 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 office visit and laboratory services provided on November 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 2 power wheelchair (PWC) with lead acid battery for enrollee.You asked the Plan to pre-approvethese services. 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. Medicare rules say that a PWC is covered when specific criteria are met.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer found the records indicate that the enrollee has a mobility limitation but that the limitation does not significantly impair his ability to perform mobility-related activities of daily living (MRADLs). The records do not contain any supporting evidence that the mobility limitation cannot be improved with an appropriately-fitted manual wheelchair. The PWC is therefore not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea Group 2 power wheelchair (PWC) with lead acid battery for enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS HF system for the enrollee.
You asked the Plan to pre-approve the system. You say that this is needed to wirelessly measure and monitor pulmonary artery pressure. The Plan denied your request. The Plan says there is no scientific research that documents this procedure's long-term effectiveness and improvement on outcomes for the treatment of heart failure.
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 system. Our reviewer says that the requested system is not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met, since the device should still be considered experimental and investigational. 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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS HF system for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental consult and extractions with an oral surgeon.
You asked the Plan to pre-approve t services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered when provided by an oral surgeon.
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. These rules say that dental services may only be provided by participating general dentists. 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, as the request is for a general surgeon to provide the consult and extractions. Therefore, we decided that the Plan does not have to pre-approve a dental consult and extractions with an oral surgeon.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four additional social work visits for the enrollee.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says there are case managers at the plan who can work with the enrollee and the family to provide additional home support.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. Medical social services can be covered as home health services under certain circumstances. 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 visits. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the documentation does not reveal a need for additional social services for assessment of the social and emotional factors related to the enrollee's illness, need for care, response to treatment and adjustment to care; for assessment of the relationship of the enrollee's medical and nursing requirements to the enrollee's home situation, financial resources and availability of community resources. There is no need for appropriate action to obtain available community resources to assist in resolving problems. The social worker has left the family with resources and options in the community. The health plan can provide additional case managers for support. The family has not completed advised paperwork, or phone calls for additional services. There is no evidence of a need for counseling services, or that the enrollee requires a medical social worker to remove a clear and direct impediment to the effective treatment of their medical condition, or to the enrollee's rate of recovery. The enrollee does not have the required conditions to qualify for social worker home health 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 the visits have not been met. Therefore, we decided that the Plan does not have to pre-approve four additional social work visits for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) and endodontic therapy (D3320) for tooth # 12.
You asked the Plan to pre-approve the dental services. You say that the crown is needed in order to save tooth # 12. The Plan denied your request. The Plan says the services do not meet criteria for coverage. The Plan says there are subcrestal caries present on tooth # 12. The Plan also says that due to this, the tooth has a poor long-term prognosis.
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 dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the requested dental services are not medically necessary. Our physician reviewer found the provided x-ray and photograph clearly show the tooth is broken down to the level of the bone. The reviewer found that the tooth is non-restorable. Therefore, if a tooth is non-restorable, endodontic treatment would not be indicated as there could be no proper seal placed on the tooth by a restoration or a crown. The reviewer found that based on the provided treatment plan of endodontics and a crown, there would be no reasonable method of sealing the tooth following root canal treatment given the clinical presentation. Without a method of being able to seal the tooth, the tooth would not be reasonably restorable, and the endodontic therapy and crown would not be medically necessary. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a crown (D2750) and endodontic therapy (D3320) for tooth # 12.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on January 7, 2020.
You asked the Plan to waive the deductible for the office visit. You say that the coverage should be the same in Florida as it is in Michigan. 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. Your contract with the Plan says that there a $1,500 out-of-network deductible that applies towards out-of-network office visits.
The office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there a $1,500 out-of-network deductible that applies towards out-of-network office visits. The record shows the provider is out-of-network.
This cost sharing is a contractual obligation that had not been met at the time the office visit was received on January 7, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on January 7, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure
You asked the Plan to pre-approve the procedure. You say that the enrollee is recommended as candidate for this device. The Plan denied your request. The Plan says this is denied as experimental and investigational.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 24, 2019.
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 emergency situation, 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 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 physician's services provided on October 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gum surgery (D4275 and D4285).
You asked the Plan to pre-approve gum surgery. You say that you need these services because you are in pain. The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan.
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 gum surgery (D4275 and D4285).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient optometry services to be provided by an
out of network (OON) provider.
You asked the Plan to pre-approve the outpatient optometry services. You say that this has been the only doctor
that has been able to diagnose your conditions. You have been working with him for months and do not want to
change doctors. The Plan denied your request. The Plan says enrollee's must receive their medical services
from an in-network provider. The plan says if an enrollee requires medical care that Medicare requires the plan
to cover and there are no in-network providers who can provide the care then the enrollee can receive the care
from an out-of-network provider. The plan has confirmed there are in-network providers available to provide
the requested services.
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 outpatient optometry services to be provided by an out of network (OON) provider.