Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.You asked the Plan to pre-approve a power wheelchair. You say that the enrollee's left leg is completely non-weight bearing.The Plan denied your request. The Plan says the records do not show the enrollee cannot use a standard manual wheelchair.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 a power wheelchair. Our physician reviewer found that the enrollee has a personal mobility deficit that impairs participation in MRADLs. The documentation reveals sufficient strength of the enrollee to ambulate with a walker one city block. The documentation does not reveal a detailed neuromuscular exam indicating that the enrollee is unable to help his mobility deficit with a manual wheelchair. Therefore, the enrollee does not meet the Medicare requirements for the requested power wheelchair.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 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 14, 2020.You asked the Plan topay for the subsequent nursing facility care. The Plan denied your request. The Plan says the claim denied correctly as there is no prior authorization on file.The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120), deep
sedation/general anesthesia - first 15 minutes (D9222) and deep sedation/general anesthesia - each subsequent
15 minute increment (D9223) provided on December 19, 2019.
You asked the Plan to pay for the dental services. You say that the services should be covered because they are
essential in order to perform the services that were prior approved and paid by the Plan. The Plan denied your
request. The Plan says the services are not a covered benefit under 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.
Current Procedural Code D6010 - Tooth #13 surgical placement of implant body; endosteal implant is a
covered service and a payment of $840 was applied but due to maxed benefit reached there is a patient
responsibility of $160.
The services are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore,
we decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120), deep
sedation/general anesthesia - first 15 minutes (D9222) and deep sedation/general anesthesia - each subsequent
15 minute increment (D9223) provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physician's services.You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the enrollee may obtain services from out-of-network providers only when providers of specialized services are not available in the network or in emergent/urgent situations.Medicare rules say that plans can require enrollees to getcare 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on February 14, 2020.
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 a hospital outpatient clinic visit provided on February 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on December 20, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for genetic testing. You say that you would like this claim reprocessed and approved
for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says
that the member's primary care physician did not refer these services. 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 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 genetic testing provided on December 20, 2019 by
an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveremoval of torus palatinus (D7472), deep sedation/general anesthesia -first 15 minutes (D9222), and deep sedation/general anesthesia -each subsequent 15 minute increment (D9223).You asked the Plan to pre-approveremoval of torus palatinus, deep sedation/general anesthesia -first 15 minutes, and deep sedation/general anesthesia -each subsequent 15 minute increment. You say that the services are necessary.The Plan denied your request. The Plan says the requested services are not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approveremoval of torus palatinus (D7472), deep sedation/general anesthesia -first 15 minutes (D9222), and deep sedation/general anesthesia -each subsequent 15 minute increment (D9223).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on March 27, 2020.You asked the Plan to waive the copayment forthe ambulance transport. The Plan denied your request. The Plan says that the claim processed 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 $265 copayment for per date of service regardless of the number of ground ambulance trips. You have been asked to pay a $265 copayment for the ambulance transport. The ambulance transport falls within the per date of service regardless of the number of ground ambulance trips 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 contractualobligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe ambulance transport provided on March 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fortranscatheter aortic valve replacement (TAVR/TAVI) (33361) provided on March 20, 2020.You asked the Plan to pay fortranscatheter aortic valve replacement. You say that this was medically necessary.The Plan denied yourrequest. The Plan says the records do not include clinical trial information.The Plan must follow Medicare rules. Medicare rules say that CMS covers transcatheter aortic valve replacement (TAVR) under CED.We looked at the file and Medicare rules. CED providescoverage of an item or service only in the context of a clinical study.The submitted records do not show that this was provided as part of a clinical trial.Based on this information, we decided that Medicare rules for coverage of transcatheteraortic valve replacement have not been met.Therefore, we decided that the Plan does not have to pay fortranscatheter aortic valve replacement (TAVR/TAVI) (33361) provided on March 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOne Touch Ultra Blue test strips.You asked the Plan to pre-approveOne Touch Ultra Blue test strips. You say that the items are 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 the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. Based on thisinformation, we decided that Medicare rules for coverage of One Touch Ultra Blue test strips have not been met. Specifically, medical records were not provided. Without this documentation, medical necessity is not able to be established.Therefore, we decided that the Plan does not have to pre-approveOne Touch Ultra Blue test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe extractions.You asked the Plan to pre-approvethe extractions. You say that this is a medical issue not a dental coverage issue. You say that you want coverage under the outpatient surgery benefit.The Plan denied your request. The Plan says you did not get additional dental coverage.Medicare generally does not cover dental services. The Planfollows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paidfor by Medicare.Therefore, we decided that the Plan does not have to pre-approvethe extractions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea privacy flap (HCPCS K0108) and a power seat elevator (HCPCS E2300).You asked the Planto pre-approvethe accessories. You say that this is medically necessary.The Plandenied your request. The Plansaysthese features are not covered.The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not a covered feature. Additionally, a privacy flap must be reported HCPCS A9270. The accessories at issue in this arenot covered. The privacy flap must be reported with a code that it is not covered. The power elevator is statutorily not covered. Based on this information, we decided that Medicare rules for coverage of the accessories have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea privacy flap (HCPCS K0108) and a power seat elevator (HCPCS E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.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 enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation provided, the enrolleedoes not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe crown and comprehensive oral evaluation provided on January 13, 2020.You asked the Plan to pay forthe crown and comprehensive oral evaluation. You say that you are appealing the denial.The Plan denied your request. The Plan says out-of-network dental services are not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay forthe crown and comprehensive oral evaluation provided on January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe corebuildup (D2950).You asked the Plan to pre-approvethe core buildup (D2950). You say that the tooth presents risk for fracture. You say that the denial should be reconsidered.The Plan denied your request. The Plan says the 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 ofMedicare 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-approvethe core buildup (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea total electric hospital bed.You asked the Plan to pre-approvea total electric hospital bed. You say that because of your medical conditions you need a new fully electric bed.The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approvea total electric hospital bed.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded G0483 provided on October 22, 2019.You asked the Plan to pay forthe drug 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 supported bythe documentation.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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition form or medical records stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing coded G0483 provided on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forantigen therapy (95165) provided on February 20, 2020.You asked the Plan to waive the copayment forthe antigen therapy. You say that you would like reconsideration because you were told there would not be a copayment for these services.The Plan denied your request. The Plan says there is a $20 copayment per visit to a specialist.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 $20 copayment for specialist services. You have been asked to pay $9.64 for the antigen therapy. The antigen therapy falls within the specialist services benefit category. The allowed amount for this service is less than $20 so you have been asked to pay the lesser amount of $9.64. This means that you have been asked to pay the lesser 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 forantigen therapy (95165) provided on February 20, 2020.Your complaint about being provided with incorrect information regarding your copayment amount is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waivethe coinsurance forthe continuous glucose monitor supplies provided on March 30, 2020.You asked the Plan to waive the coinsurance forthe continuous glucose monitor supplies. You say that you were told there would be no cost.The Plan denied your request. The Plan says that the claim processed 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 20% coinsurance for durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for the continuous glucose monitor supplies. The continuous glucose monitor supplies fall within the durable medical equipment (DME) and related supplies 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 coinsurance forthe continuous glucose monitor supplies provided on March 30, 2020.