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

We decided that the Plan does not have to pay for the hearing aid provided on October 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the hearing aid. You say that this should be covered by the Plan. The Plan denied your request. The Plan says that these services were available with network providers.
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 had network providers available who could have provided 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 hearing aid provided on October 10, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic office visit and spine x-ray provided on August 19, 2020.
You asked the Plan to pay for the chiropractic office visit and spine x-ray. You say that the chiropractor submitted the claim wrong. The Plan denied your request. The Plan says the chiropractic office visit and spine x-ray are not a covered benefit.
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 chiropractic office visit and spine x-ray provided on August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgery provided by an out-of-network provider on August 18, 2020.
You asked the Plan to pay for the outpatient surgery. You say that the procedures were necessary, and the claim should be paid. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 outpatient surgery provided by an out-of-network provider on August 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient therapy services rendered from September 1,
2020, to September 22, 2020.
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 procedure codes 97530, 97110, and 97535 are 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 97530 is therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. The definition
of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop
strength and endurance, range of motion and flexibility. The definition of code 97535 is self-care/home
management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety
procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one
contact, each 15 minutes.
We find that CPT codes 97530, 97110, and 97535 are not supported in the medical record. Specifically, there is
no documentation does not support that 15 minutes was spent on therapeutic activities to support code 97530.
There is no documentation of a total of 23 to 30 minutes of therapeutic procedures to support two units of code
97110. There is no documentation of a total of 38 to 45 minutes of self-care/home management training to
support three units of code 97535.
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 outpatient therapy services rendered from
September 1, 2020, to September 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for extracapsular cataract removal with insertion of intraocular lens prosthesis provided on August 7, 2020.
You asked the Plan to pay for the extracapsular cataract removal with insertion of intraocular lens prosthesis. 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 this service. Therefore, we decided that the Plan does not have to pay for extracapsular cataract removal with insertion of intraocular lens prosthesis provided on August 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on October 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for genetic testing. You say that this testing meets Medicare coverage criteria. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan, the ordering physician is also out-of-network, and this testing was not medically necessary.
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 ordering physician is also out-of-network 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 October 2, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous image-guided lumbar decompression
(PILD) procedure.
You asked the Plan to pre-approve a PILD procedure. You say that the requested PILD procedure is medically
necessary. The Plan denied your request. The Plan says the enrollee is not enrolled in a clinical study.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.
We looked at the file and Medicare rules. Medicare rules say that percutaneous image-guided lumbar
decompression or commercially known as the mild procedure will be covered when provided in an approved
clinical study. The file does not show that the enrollee is enrolled in an approved clinical study. Therefore, we
decided that the Plan does not have to pre-approve a percutaneous image-guided lumbar decompression (PILD)
procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a follow up visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a follow up visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a 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 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 a follow up visit to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81405, 81406, 81408, 81479) provided on July 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON laboratory services. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.
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 had network providers available who could have provided 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 laboratory services (81405, 81406, 81408, 81479) provided on July 23, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown, core build up, and 4 fillings provided on May 29, 2019.
You asked the Plan to pay for the dental services. You say that this dental work was a direct result from damage to your teeth caused by radiation treatments. You say that you had 37 radiation treatments. You also say that you were aware from the start that there would be dental work after the fact. The Plan denied your request. The Plan says crown is not listed as a covered service. The Plan says that core build up is not listed as a covered service. The Plan also says that fillings are not listed as covered services either.
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 pay for the crown, core build up, and 4 fillings provided on May 29, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the Covid-19 testing provided on November 12, 2020.
You asked the Plan to pay for the laboratory testing. You say that the provider is an independent laboratory serving nationwide. You say that the provider had no knowledge of the enrollee's coverage prior to doing their part in providing timely testing and results. You also say that the service should be covered. The Plan denied your request. The Plan says the enrollee'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. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the Covid-19 testing provided on November 12, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 home health visits.

You asked the Plan to pre-approve the 7 home health visits. You say that you would like reconsideration because you hope to gain movement back in your arm with injections and additional therapy. The Plan denied your request. The Plan says the requested services are not reasonable and necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the 7 home health visits. Our reviewer says that the documentation does not support that you require additional skilled rehab services to provide treatment that is medically necessary. Our physician reviewer found the member does not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain your condition and/or prevent deterioration.

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 7 home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 home health visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on
September 20, 2020.
You asked the Plan to pay for the diagnostic radiology services. 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 diagnostic radiology services. 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 diagnostic radiology services provided on September 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an MRI scan to be provided by an OON provider. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a 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 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 a magnetic resonance imaging (MRI) scan to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on January 24, 2020.
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 procedure code 99291 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 30 to 74 minutes of critical care services spent on the enrollee. 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 critical care services rendered on January 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921) and localized delivery of antimicrobial agents (D4381) provided on January 8, 2020.
You asked the Plan to pay for the gingival irrigation and antimicrobial agent insertion services. You say that this service was necessary to save your teeth and should be covered under the benefit. The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan's supplemental dental 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 pay for the gingival irrigation (D4921) and localized delivery of antimicrobial agents (D4381) provided on January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for COVID-19 testing (G2024, U0003).

You asked the Plan to pay for COVID-19 testing. You say that these were valid codes for the date of service billed. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.

We looked at the file and Medicare rules. The submit records do not include documentation that shows the ordering physician was treating the beneficiary. Based on this information, we decided that Medicare rules for coverage of COVID-19 testing have not been met. Therefore, we decided that the Plan does not have to pay for COVID-19 testing (G2024, U0003).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for implant supported crowns (D6066) for teeth # 10 and 11 provided on January 5, 2021.
You asked the Plan to pay for the dental services. You say that you were not advised that implant supported crowns are not covered. You also say that you feel that you should not be responsible for the full cost share for these services. The Plan denied your request. The Plan says implant supported crowns are not listed as covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The Evidence of Coverage clearly states that any dental services not listed are not covered. Additionally, the record shows that you did not call the Plan to verify your benefits. Therefore, we decided that the Plan does not have to pay for implant supported crowns (D6066) for teeth # 10 and 11 provided on January 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the powered mobility device (K0899) provided on September 24, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the powered mobility device. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says you did not obtain prior authorization prior to the services being rendered.
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 had network providers available who could have provided 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 powered mobility device (K0899) provided on September 24, 2020, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab testing (81286, 81403, 81404, 81405, 81406, 81407, 81408, 81479) provided September 11, 2020.
You asked the Plan to pay for the lab testing. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. We looked at the file and Medicare rules. The cardiovascular risk assessment testing is not covered. Based on this information, we decided that Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not have to pay for lab testing (81286, 81403, 81404, 81405, 81406, 81407, 81408, 81479) provided September 11, 2020.