Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-care/home management training, electrical stimulation services, therapeutic procedure, and the office visit.

You asked the Plan to pay for the self-care/home management training, electrical stimulation services, therapeutic procedure, and the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received 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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the self-care/home management training, electrical stimulation services, therapeutic procedure, and the office visit.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (97161) provided by an OON provider.

You asked the Plan to pay for the physical therapy. You say that you were told services were approved for 20
visits, so you moved forward with the provider's treatment plan. You say these services were medically
necessary. The Plan denied your request. The Plan says they did not review or approve a prior authorization
request for these sessions. The Plan only covers out of network care in limited circumstances, and the contract
clearly states that an out of network provider is always required to seek prior authorization. In addition, most of
the medical records submitted were encrypted or illegible, so the Plan was unable to approve a prior
authorization retroactively.

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 physical therapy (97161) provided 
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDX testing provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the criteria was not 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee does not meet the coverage criteria for the requested testing. The enrollee had a first prostate biopsy for elevated PSA of 4.1.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDX testing provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit for wound care (99308) provided by an out of network (OON) provider.

You asked the Plan to pay for the nursing facility visit for wound care. You say that the services were medically necessary. The Plan denied your request. The Plan says the services provided did not meet OON criteria.

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 nursing facility visit for wound care (99308) provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pelvis x-ray.

You asked the Plan to waive the copayment for the pelvis x-ray. You say that you had an x-ray during a visit with a specialist at his office. The Plan denied your request. The Plan says the copayment applied 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 $110 copayment for basic radiological services at an in-network outpatient hospital.

You have been asked to pay a $110 copayment for the pelvis x-ray. The pelvis x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show the x-ray was billed by the hospital. 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 the pelvis x-ray.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy and self-care management training provided by a participating provider.

You asked the Plan to waive the copayment for physical therapy and self-care management training. You say that you do not agree with these copayments. The Plan denied your request. The Plan says the correct copayment 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 outpatient rehabilitation services for outpatient rehabilitation services.

You have been asked to pay outpatient rehabilitation services for physical therapy and self-care management training. When multiple services are provided during one visit, multiple copayments are applied. The total amount you are being asked to pay is $70 ($35 (physical therapy) + $35 (self-care training) = $70). Physical therapy and self-care management training falls within the outpatient rehabilitation 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 copayment for physical therapy and self-care management training provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D2752, D2954).

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a benefit in your dental coverage.

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 dental services (D2752, D2954).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the echo exam of the eye and the Medicare-covered eye exam.

You asked the Plan to waive the copayments for the echo exam of the eye and the Medicare-covered eye exam. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an outpatient diagnostic test and an eye exam on the date of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.

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 $10 copayment for Outpatient diagnostic tests and a $20 copayment for the Medicare-covered eye exam.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an echo exam of the eye and a Medicare-covered eye exam. You have been asked to pay a $10 copayment for the echo exam of the eye. The echo exam of the eye falls within the Outpatient diagnostic tests benefit category. You have also been asked to pay a $20 copayment for the Medicare-covered eye exam. The Medicare-covered eye exam falls within the Vision care benefit category. This means that you have been asked to pay the correct amounts 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 the echo exam of the eye and the Medicare-covered eye exam.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services (11042, 97597) rendered by the out of network (OON) provider.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization. Additionally, the services provided were not urgent or emergent.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 for the debridement services (11042, 97597) rendered by the out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone graft.

You asked the Plan to pay for these services. You say that you would like reimbursement. The Plan denied your request. The Plan says the services 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone graft.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cranioplasty (62141) provided on April 21, 2020.
You asked the Plan to pay for the cranioplasty. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
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 62141 is cranioplasty for skull defect; larger than 5 cm diameter. We asked our coder 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 cranioplasty. Our reviewer says that CPT code 62141 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not included documentation indicating the size of the skull defect, therefore this procedure cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cranioplasty have not been met. Therefore, we decided that the Plan does not have to pay for the cranioplasty (62141) provided on April 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the treatment of a root canal obstruction (D3331) to be
provided by an endodontist.

You asked the Plan to pre-approve the dental service. You say that your tooth is broken. You say that the tooth
does not have enough space to install a crown. You say that a root canal is required for tooth # 2. You also say
that you were referred to an endodontist for the root canal. You also say that you cannot afford to pay for this
procedure. The Plan denied your request. The Plan says treatment of root canal obstruction is not a covered
service. The Plan says that services must be performed by a participating general dentist. The Plan also says
that service provided by an endodontist 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
among those covered under this benefit. Additionally, services must be performed by a participating general
dentist. Therefore, we decided that the Plan does not have to pre-approve the treatment of a root canal
obstruction (D3331) to be provided by an endodontist.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc 850 (J7320).

You asked the Plan to pre-approve Genvisc 850. You say that there is no reason that the requested drug should be denied. The Plan denied your request. The Plan says the documentation provided does not show that the enrollee has tried and failed the preferred drugs.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Genvisc 850. Our reviewer says that Genovisc 850 is not medically necessary. Our physician reviewer found the provided documentation shows that the enrollee has not tried and failed the required drugs. The reviewer found there is no documentation provided indicating that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the requested drug, Genvisc 850, is not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Genvisc 850 have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc 850 (J7320).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (CPT 97112) received on August 25, 2020.
You asked the Plan to pay for the services. You say that deep tissue massage is needed as it helps with medical issues. The Plan denied your request. The Plan says this is not a covered benefit, because Medicare does not cover non-manipulative services by chiropractors.
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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services (CPT 97112) received on August 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aprepitant for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve aprepitant for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve expandable controller and related parts (E2377, E2313, E2311).

You asked the Plan to pre-approve expandable controller and related parts. You say that these items are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says there is not a medical need to control these power options through the joystick.

The Plan follows Medicare rules. Medicare rules say that an expandable controller is subject to specific criteria as listed in the Rules section. 

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 expandable controller and related parts. Our reviewer says that the requested items are not medically reasonable and necessary. Our physician reviewer found the documentation does not reveal that the patient requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The patient does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The patient's upper extremity strength is sufficient to control any power options through their own individual switches. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of expandable controller and related parts have not been met. Therefore, we decided that the Plan does not have to pre-approve expandable controller and related parts (E2377, E2313, E2311).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hospital observation services (G0378, 93005, 99285) provided July 29, 2020 to July 30, 2020.
You asked the Plan to waive the copayment for the observation care. You say that you were admitted to the hospital and the copayment should be waived. The Plan denied your request. The Plan says the records show you were not admitted as an inpatient, so the correct copayment was 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 $50 copayment for outpatient hospital observation. You have been asked to pay a $50 copayment for the observation care. The observation care falls within the outpatient hospital observation 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 hospital observation services (G0378, 93005, 99285) provided July 29, 2020 to July 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lumbar sacral orthosis (L0650) and shoulder elbow wrist hand orthosis (L3960).
You asked the Plan to pre-approve the lumbar sacral orthosis and shoulder elbow wrist hand orthosis. You say that these items were medically necessary for the enrollee. The Plan denied your request. The Plan says the prescribing physician did not discuss these items with the enrollee.
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 lumbar sacral orthosis and shoulder elbow wrist hand orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back. Furthermore, regarding the shoulder orthosis, a physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the shoulder. 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 lumbar sacral orthosis and shoulder elbow wrist hand orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the lumbar sacral orthosis (L0650) and shoulder elbow wrist hand orthosis (L3960).