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

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation and extraction provided on November 12, 2019.
You asked the Plan to pay for the bone replacement graft and extraction. You say that you had no way to relieve the pain and immediate attention was essential. You also say it was impossible to get pre-approved for the surgery at that time. The Plan denied your request. The Plan says no calls were made prior to the services to verify your benefits. The Plan also says that these services are non-covered dental 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, the requested items or services are not among those covered under this benefit. The Plan only allows coverage for 1 simple extraction per year, surgical extractions are not covered. Therefore, we decided that the Plan does not have to pay for the bone replacement graft for ridge preservation and extraction provided on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a heart-lung machine provided on November 19, 2019.You asked the Plan to pay for the heart-lung machine operation. You say that this service is medically necessary and should be paid by the plan.The Plan denied your request. The Plan says payment for this service is included in payment to the facility for the inpatient stay. No separate payment is made.The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.Although these services may be appropriate, payment for them is made to the hospital which must then furnish these services either directly or under arrangements. As such, separate Medicare payment cannot be made for the services at issue.Therefore, we decided that the Plan does not have to pay for the assembly and operation of a heart-lung machine provided on November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveout of network office visits are not a covered benefit for non-urgent care.You asked the Plan to pre-approveout of network services. You say that this treatment is medically necessary.The Plan denied your request. The Plan says it is not medically necessary to see an out of network provider.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 provider at issue in this case is not a network provider with the Plan. 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 out of network services. Our reviewer says that out of network medical necessity has not been established. Our physician reviewer found you were evaluated for ear pain prior to leaving the service area.You have been evaluated by two providers, and no urgent or emergent medical condition involving the ears has been identified.Medicarecriteria for out of network medical necessity are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of out of network services have not been met. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve out of network services.Therefore, we decided that the Plan does not have to pre-approveout of network office visits are not a covered benefit for non-urgent care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the next generation sequencing (NGS) rendered to the enrollee on October 10, 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 were not medically necessary. The Plan must follow Medicare rules. Medicare rules say that NGS 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a personal history of malignant neoplasm of the breast. She has had two diagnoses of breast cancer in her left breast and underwent lumpectomy in 1993 and mastectomy in 1998. The documentation does not support that the enrollee has a diagnosis of either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer, and has decided to seek further cancer treatment such as therapeutic chemotherapy. It has not been demonstrated that this testing would impact the health management of the enrollee; therefore, the testing was 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 pay for the next generation sequencing (NGS) rendered to the enrollee on October 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on October 1, 2019.
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on October 1, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from August 6, 2019 to August 25, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the claim was missing the visit with the appropriate G code for the billed dates of service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.We find that HCPCS codes Q5001, S9123, S9131 is not supported in the medical record. Specifically, the claim was not billed with the appropriate G code. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from August 6, 2019 to August 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99201) and does not have to waive the cost sharing applied for the chiropractic manipulative treatment (98940) provided on November 8, 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 that the claim was processed correctly for the services. 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 Plan contract states that you are responsible for a $20 copayment for Medicare covered chiropractic services. The Medicare allowable amount for the spinal manipulation was $16.80, which was the copayment assessed for these services. The office visit is not a covered service by Medicare or the health plan. Therefore, we have decided that the Plan does not have to pay for the office visit (99201). Additionally, the Plan does not
have to waive the cost sharing applied for the chiropractic manipulative treatment (98940) provided on November 8, 2019.
Appeal type: Practitioner Services
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 the referral. You say that you would like reconsideration as the member has been seeing this provider since 2016. The Plan denied your request. The Plan says there are in-network providers available who can safely render the requested service.
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 provider at issue in this case is not a network provider with the Plan. 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 referral. Our reviewer says that the documentation does not support the medical necessity of out of network care. Our physician reviewer found there is nothing in the documentation suggesting that the member requires services that must be performed out of network. There is no documentation suggesting that there is an emergency or urgency. There is no evidence in the medical record that would suggest transitioning to an in-network provider would be unsafe. 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 referral have not been met. 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 the referral. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for infrared therapy (97026) provided on May 2, 2019 through May 28, 2019.
You asked the Plan to pay for the infrared therapy. You say that you would like reconsideration because these services are not available in the Plan's network. The Plan denied your request. The Plan says the service is not covered by Medicare and the provider is not hired to offer services with the Plan.
The Plan must follow Medicare rules. Medicare rules say that infrared therapy is noncovered for all indications. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the infrared therapy have not been met. Specifically, per the LCD, the infrared therapy therapy is noncovered. Therefore, we decided that the Plan does not have to pay for infrared therapy (97026) provided on May 2, 2019 through May 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral - periapical, first film (D0220) provided January 10, 2020.
You asked the Plan to pay for the dental x-rays. You say that you request reconsideration because the provider initially wanted to do panoramic x-rays but then said he will do the regular ones. You that that the regular ones would be the ones covered by the plan. The Plan denied your request. The Plan says this service is not covered under the benefits package.
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. Only bitewing x-rays are covered under the plan benefits. 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 intraoral - periapical, first film (D0220) provided January 10, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy services (90832, 90834, 90837 and 99213).
You asked the Plan to pre-approve the psychotherapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services are not medically necessary as you are not planning to hurt yourself or others.
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 psychotherapy services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request for additional therapy is not considered reasonable or medically necessary due to your improvement of mood symptoms and no description of your mood symptoms interfering with your function. 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 psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve psychotherapy services (90832, 90834, 90837 and 99213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device and sleeves provided to the enrollee on October 3, 2019.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says the billed services were not supported.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The proof of delivery provided does not indicate the supplies provided. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and sleeves provided to the enrollee on October 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips beyond the 44 allowed per calendar year.
You asked the Plan to pre-approve the additional routine transportation trips. You say that the enrollee needs a continuation of coverage for routine transportation in order to get to her life saving treatments. You say that the serious nature of the enrollee's condition justifies the need for this requested coverage. The Plan denied your request. The Plan says the benefit for routine transportation trips have been exhausted for the 2020 calendar year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 44 trips per year. We looked at your request, the records in the case file, and the rules. The case file submitted shows that you are requesting coverage for routine transportation trips exceeding 44 for the 2020 calendar year. Based on this information, we decided that your request would exhaust the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips beyond the 44 allowed per calendar year.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on July 24, 2019 to July 29, 2019.
You asked the Plan to pay for services. You say that the claims should be paid for all dates of service. The Plan denied your request. The Plan says the member's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on July 24, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for services provided to the enrollee on July 24, 2019 to July 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp.
You asked the Plan to pre-approve the wheelchair ramp. You say that you had a recent hip surgery and need the temporary ramp for outside of your home. The Plan denied your request. The Plan says the item being requested is not a covered benefit.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for needle electromyography (95870) provided on September 26, 2019.
You asked the Plan to pay for needle electromyography. You say that this was a medically necessary service. The Plan denied your request. The Plan says that the records do not support this service.
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 95870 is needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters. 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 needle electromyography. Our reviewer says that the documentation is sufficient to support the billing of CPT 95870. Our physician reviewer found the enrollee received intraoperative neurophysiologic monitoring while undergoing cervical spine surgery. The monitoring report notes that bilateral, upper extremity, free-running EMGs were performed. By definition, the performance of an EMG requires the insertion of needles, which are small and are often referred to as electrodes. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography have been met. Therefore, we decided that the Plan has to pay for needle electromyography (95870) provided on September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment received from August 13, 2019
to October 13, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the claims would be covered by Original Medicare until the first day of the following month in
which hospice was revoked.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for durable medical equipment received from August 13, 2019 to
October 13, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on August 28, 2019.
You asked the Plan to pay for services. You say that the claims should be paid because it meets Medicare criteria. The Plan denied your request. The Plan says during the election of Hospice, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for services provided to the enrollee on August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 6, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because you were in the hospital receiving a surgery. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $45 copayment per specialist visit. The medical records show that you received specialist services on August 6, 2019. Therefore, you are responsible to pay the $45 copayment. You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on August 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided December 9, 2019.
You asked the Plan to pay for the x-rays. You say that you were having sinus and jaw pain and was going to be flying on a plane and was concerned the pressure of the flight would be a problem. The Plan denied your request. The Plan says this request exceeds the benefit frequency limit.
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. This service is covered once every 12 months. Records show that this service was provided December 17, 2018. Coverage for this service was not available until December 17, 2019. 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 bitewing x-rays (D0274) provided December 9, 2019.