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

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy of the device. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prostatectomy provided from May 7, 2020, to May 8, 2020 while out of the service area.
You asked the Plan to pay for the prostatectomy provided while out of the service area. You say that you could not return home sooner because of a health emergency and the COVID-19 pandemic. The Plan denied your request. The Plan says the prostatectomy could have been delayed until the you returned to a network provider.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.
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 prostatectomy provided while out of the
service area. Our reviewer says that the enrollee could not have foreseen requiring the services prior to leaving
his service area. Our physician reviewer found it would have been medically reasonable to delay the services
until the enrollee returned to his service area on February 11, 2021. The condition itself was not urgent/
emergent as the catheter could have been irrigated/flushed and the enrollee could have awaited definitive
treatment as the issue was not life/limb/organ threatening.
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 prostatectomy provided while out of the service area have not been met.
Therefore, we decided that the Plan does not have to pay for the prostatectomy provided from May 7, 2020, to
May 8, 2020 while out of the service area.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous positive airway pressure (CPAP) supplies purchased from a non-Medicare supplier on February 25, 2021.
You asked the Plan to pay for CPAP supplies. You say that these supplies are necessary for use of your CPAP, and it is your understanding that these supplies are a covered expense which should be reimbursed. The Plan denied your request. The Plan says the denial of payment for these supplies is correct, because this provider is not enrolled in the Medicare program and is not payable.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for Medicare items or services, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. This supplier is a retailer which is not enrolled in the Medicare
program and is therefore not payable. Based on this information, we decided that Medicare rules for coverage of CPAP supplies have not been met. Therefore, we decided that the Plan does not have to pay for continuous positive airway pressure (CPAP) supplies purchased from a non-Medicare supplier on February 25, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a left heart catheterization procedure.
You asked the Plan to pre-approve the left heart catheter procedure. You say that this is medically necessary due to the high likelihood of coronary artery disease. The Plan denied your request. The Plan says that complete non-invasive testing has not been done prior to invasive surgery.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 left heart catheter procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 79-year-old man with a medical history of hyperlipidemia, chronic obstructive pulmonary disease (COPD) and transient ischemic attacks (TIA). The enrollee smoked 1 pack per day for 55 years. At a cardiology appointment on 6/14/21, the enrollee reported lingering left-sided achy chest pain. A coronary calcium score on 6/28/21 was 3965, indicating a high likelihood of at least one significant coronary artery stenosis (greater than 70% stenosis). In this case, the enrollee's risk factors for coronary artery disease include age, gender, hyperlipidemia, and smoking. The enrollee reported chest pain at rest, and his coronary calcium score indicated a high likelihood of significant coronary artery stenosis. A left heart catheterization to diagnose and potentially treat coronary artery stenosis is medically reasonable and necessary for the enrollee in this case. The documentation does not support that coronary computed tomography angiography is medically reasonable and necessary prior to left heart catheterization. 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 left heart catheter procedure have been met. Therefore, we decided that the Plan has to pre-approve a left heart catheterization procedure.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for orthotics provided by a participating provider on March 11, 2021.

You asked the Plan to waive the coinsurance for orthotics. You say that you believe that you and the Plan are being ripped off. The Plan denied your request. The Plan says the correct coinsurance has been applied.

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. 

You have been asked to pay a 20% coinsurance of the allowed amount for orthotics. The total allowed amount is $932.38. The total amount you are being asked to pay is $186.48 ($932.38 x 20 % = $186.48). The correct coinsurance has been applied to the services that were provided. Orthotics fall within the durable medical equipment 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 orthotics provided by a participating provider on March 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, ribs, unilateral (71100) provided on February 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the diagnostic service. You say that the claims were denied due to lack of referral and/or authorization but these services do not require referral. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before 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 radiologic examination, ribs, unilateral (71100) provided on February 9, 2021 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 hearing aids provided on March 4, 2021.
You asked the Plan to pay for the hearing aids. You say that the Annual Notice of Changes lists $100 allowance every year and coverage does not specify in or out-of-network. You say that you can go anywhere to get a hearing aid and have it be covered. The Plan denied your request. The Plan says there was no authorization on file for the out-of-network provider and in-network providers were available.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are received from a network provider.
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on March 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 home health nursing visits (G0299) and 5 physical therapy visits (G0151).
You asked the Plan to pre-approve 5 home health nursing and physical therapy visits. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated in a lower level of care.
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 5 home health nursing and physical therapy visits. Our reviewer says that the requested home health visits are not medically necessary. Our physician reviewer found the submitted medical records do not document any acute medical conditions or physical needs that cannot be met by the enrollee's caregivers in the assisted living facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 5 home health nursing and physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 home health nursing visits (G0299) and 5 physical therapy visits (G0151).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on February 8, 2021 to February 15, 2021.
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 are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered.
Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on February 8, 2021 to February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on April 29, 2020 by an out-of-network provider.
You asked the Plan to pay for the lumbar-sacral orthosis (L0648). You say that you would like the Plan to pay for the orthosis. The Plan denied your request. The Plan says there are in-network providers in your area that could have provided the orthosis.
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 item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on April 29, 2020 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for urgently needed services provided from December 6, 2020, to March 13, 2021.
You asked the Plan to waive the copayments for urgently needed services. You say that you feel that you wanted to be seen by your primary care physician but they told you to go to urgent care. 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 for urgently needed services. You received urgently needed services from December 6, 2020, to March 13, 2021 for a total of 3 visits. Therefore, you are responsible to pay a $45 copayment per each visit. The total amount you owe is: $135.
You have been asked to pay the total copayment amount of $135 for urgently needed services. Urgently needed services fall within the urgently needed services 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 copayments for urgently needed services provided from December 6, 2020, to March 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 24, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that the provider did not inform you of the charges and you feel that that is fraudulent. 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 for specialist visits. 

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 March 24, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for laparoscopy, surgical (44205) provided March 12, 2021.
You asked the Plan to pay for the laparoscopy. You say that the records attached supporting that this procedure
was performed by your provider. Claim denied as duplicate in error. Please review and reprocess the claim for
reimbursement according to contract. The Plan denied your request. The Plan says the number of days or units
of service exceeds the acceptable maximum.
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 44205 is laparoscopy, surgical, colectomy, partial, with
removal of terminal ileum with ileocolostomy.
We find that CPT code 44205 is not supported in the medical record. Specifically, the records show that 44205
was billed for the same date of service by the same provider was paid and processed May 13, 2021. Based on
this information, we decided that Medicare rules for coverage of the laparoscopy have not been met. Therefore,
we decided that the Plan does not have to pay for laparoscopy, surgical (44205) provided March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental procedures provided on March 16, 2021.
You asked the Plan to waive the coinsurance and pay for the comprehensive periodontal evaluation. You say that your dentist sent you to another dentist to perform the same service. The Plan denied your request. The Plan says you were charged 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 one exam every 6 months is covered. You have been asked to pay for the comprehensive exam. The dental exam falls within the Dental Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 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. Therefore, we decided that the Plan does not have to pay for the dental procedures provided on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on April 16, 2021, by an OON provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that a Plan representative advised you that the treating provider cancelled her contract with the Plan on September 21, 2020, but the provider states her office did not contact the Plan to cancel the contract. You also say that you feel these services should be covered. The Plan denied your request. The Plan says the treating provider is not part of the Plan's dental vendor network. The Plan also says that services rendered by a provider who is not in-network are not covered.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on April 16, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for a mulled ankle support provided on March 4, 2021.
You asked the Plan to pay for the mulled ankle support. You say that the item in dispute was needed during physical therapy and general walking in order the lesson the stress on the micro-fracture of the tibia. You say that the item in dispute allowed for further healing once the lab boot was no longer required. You say that this item also supported your ankle. The Plan denied your request. The Plan says that the guidelines for coverage of the item have not been met.
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 to the non-contracted durable medical equipment provider (who supplied the mulled ankle support) by a contracted provider. The file does not show that the Plan provided notice that the mulled ankle support would not be covered. Under Medicare rules, this means the mulled ankle support is considered approved by the Plan. Therefore, we decided that the Plan has to pay for a mulled ankle support provided on March 4, 2021.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy with an out-of-network provider.
You asked the Plan to pre-approve out-of-network physical therapy. You say that you are being treated in preparation of surgery and you want to continue physical therapy services at the same office. You say that you cannot wait 30 days with a torn meniscus. The Plan denied your request. The Plan says services are available in-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 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
physical therapy with an out-of-network provider.