Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve T12 12 vertebral augmentation for the enrollee.You asked the Plan to pre-approvethe surgery. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee meet the criteria for the procedure at T10, but not at T12.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found kyphoplasty remains experimental for the treatment of vertebral compression fractures. Recent literature shows it is not more effective than sham treatment for compression fractures. More research is needed. It is not needed at T12.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have not been met.Therefore, we decided thatthe Plan does not have to pre-approveT12 12 vertebral augmentation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine eye exam provided on November 1, 2019.
You asked the Plan to pay for the routine eye exam. The Plan denied your request. The Plan says there is no benefit for an additional routine eye exam in 2019.
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to 1 routine eye exam per year. We looked at the file and the Plan's rules. The file shows that the Plan covered a routine eye exam provided on July 29, 2019. The Plan routine eye exam coverage is limited to 1 per year. Based on this information, we decided that the Plan's rules for coverage of the routine eye exam have not been met. Therefore, we decided that the Plan does not have to pay for a routine eye exam provided on November 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep cleaning, full mouth debridement (D4355).You asked the Plan to pre-approve the deep cleaning. You say that you are appealing to be seen by a periodontist because you really need to be treated due to having issues.The Plan denied your request. The Plan says the requested 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 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 deep cleaning,full mouth debridement (D4355).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to enrollee on September 11, 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 procedure code 95937 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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.We find that CPT code 95937 is not supported in the medical record. Specifically, the file shows that Train of Four testing was performed and there is a more appropriate code for these services. 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 services rendered to enrollee on September 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe surgical extractions of teeth 7, 8, 9, 11, 13, 14, 21, 22, 23, (D7210) and alveoplasty (LL, UL and UR) (D7320).You asked the Plan to pre-approvethe surgical extractions and alveoplasty. You say that the enrollee has been going through a lot of pain do to his teeth rotting and breaking off and due to his heart problems he needs oral surgery for them to be removed.The Plan denied your request. The Plan says the requested services are not covered under the benefitsMedicare 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 health plan contract specifically states that the plan covers simple extractions.Though the Planoffers 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-approvethe surgical extractions of teeth 7, 8, 9, 11, 13,14, 21, 22, 23, (D7210) and alveoplasty (LL, UL and UR) (D7320).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide Suction Seal-In Electrodes, and Be Myo Silicone Socket, Prepreg, Valve.You asked the Plan to provide Suction Seal-In Electrodes (L7499), and Be MyoSilicone Socket, Prepreg, Valve (L7499). You say that a silicone socket will secure the fit and the suction seal-in electrodes is not a duplicate electrode.The Plan denied your request. The Plan says these additions cannot be requested separately from the approved terminal device.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, we have confirmed that code Suction Seal-In Electrodes (L7499), and Be Myo Silicone Socket, Prepreg, Valve (L7499) havea bundled relationship with code L7009and cannot be paid ifbilled. Thesecodescannot be paid as a separate line item. Medicare billing criteria would not be met.Therefore, we decided that the Plan does not have to providetheSuction Seal-In Electrodes, and Be Myo Silicone Socket, Prepreg, Valve.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 2, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the anesthesia for surgery provided on October 11, 2019.
You asked the Plan to reduce the coinsurance for the surgical anesthesia. You say that you were told this service would be covered at the in-network rate. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 30% coinsurance for surgery services at an out-of-network outpatient hospital. You have been asked to pay $32.58 which is 30% of the allowed amount for the surgical anesthesia. The allowed amount is $108.59. ($108.59 x 30% = $32.58). The surgical anesthesia falls within the "Outpatient hospital services" benefit category. The record shows the provider is out-of-network.
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 reduce the coinsurance for the anesthesia for surgery provided on October 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve interim partial denture (upper) (D5820).
You asked the Plan to pre-approve interim partial denture. You say that your feeding tube was taken out before
dental services was provided and you are not able to eat due to no partial. The Plan denied your request. The
Plan says this 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 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
interim partial denture (upper) (D5820).
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the remaining mileage for the claim of services provided on October 19, 2019.
You asked the Plan to pay for the additional 45 miles of air ambulance services. You say that the physician had the transport arranged. The Plan denied your request. The Plan says that you were not transported to the nearest appropriate facility.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the additional 45 miles of air ambulance services by the facility. The facility is a contract provider. The file does not show that the Plan provided notice that the 45 miles of air ambulance services would not be covered. Under Medicare rules, this means the 45 miles of air ambulance services is considered approved. Therefore, we decided that the Plan has to pay for the remaining mileage for the claim of services provided on October 19, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on September 23, 2019.
You asked the Plan to waive the copay for the ambulance transport. You say that you did not request this 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 $200 copay for each covered, one-way ambulance trip by ground or water. You have been asked to pay a $200 copay for the ambulance transport. The ambulance transport falls within the covered, one-way ambulance trip by ground or water 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 copay for the ambulance transport provided on September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a visual field examination provided on July 31, 2019.
You asked the Plan to waive the copayment for a visual field examination. You say that you already paid your $50 copayment and disagree with the additional $20 charge. 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 $20 copayment for outpatient diagnostic procedures and tests. You have been asked to pay a $20 copayment for a visual field examination. A visual field examination falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for a visual field examination provided on July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided  on August 16, 2019 to September 11, 2019 by an out of network (OON) provider.You asked the Plan to pay for nursing facility care. You say that the patient is a resident of a nursing home and was seen by this doctor while making daily rounds.The Plan denied your request. The Plan says the physician providing these services is out-of-network. The Plan says that no prior authorization was obtained for these 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for nursing facility care provided  on August 16, 2019 to September 11, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional mileage for routine transportation.You asked the Plan to pre-approveadditional mileage. The Plan denied your request. The Plan says the benefit only allows for 50 miles per trip.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 50 miles per one-way trip. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the requested additional mileage will exceed the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approveadditional mileage for routine transportation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services (13151 and 17311) provided on October 3, 2019 by an out of network (OON) provider.You asked the Plan to pay for OON surgical services. You say that you were told these services did not require authorization.The Plan denied your request. The Plan says OON services require authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the surgical services (13151 and 17311) provided on October 3, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on March 8, 2019.You asked the Plan to pay forthe services. The Plandenied your request. The Plan says the services require authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. 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 forthe medical services provided to you by an out-of-network provider on March 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on February 28, 2019.You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing provided by on February 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Advocate Redi-Code test strips to be provided by an out of network provider.You asked the Plan to pre-approvethe test strips. You say that the enrollee's facility uses the Advocate Redi-Code test strips.The Plan denied your request. The Plan says a participating provider and is able to ship Freestyle brand test strips.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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items.Therefore, we decided that the Plan does not have to pre-approveAdvocate Redi-Code test strips to be provided by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Monovisc injection provided on February 13, 2019.You asked the Plan to waive the coinsurance for the injection. You say that you were not informed there would be any out-of-pocket fee.The Plan denied your request. The Plan says that they require a 20% coinsurance for each Medicare-covered Part B drug.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 Medicare Part B Prescription Drugs. You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Medicare Part B Prescription Drugs 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 for the Monovisc injection provided on February 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3020).
You asked the Plan to pre-approve foot orthotics. You say that you are feeling pain on your legs and you are being treated for your hip because your walking is affecting that area. The inserts will help to reduce the pain. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Gammagard (J1569) for the enrollee.You asked the Plan to pay for the injection. You say that this is medically necessary.The Plan denied your request. The Plan says criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee was noted to have throbocytopenia with a platelet count of 4000 on 2/23/20 which improved to 45000 on 2/25 after taking prednisone. The specialist indicated her condition may be related to medication or a recent infection process. There was no active bleeding, headache or plan for surgery. LCD criteria were not met and medical necessity is not determined.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met.Therefore, we decided that the Plan does not have to pay for Gammagard (J1569) for the enrollee.