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

We decided that the Plan does not have to pre-approve a High Frequency Chest Wall Oscillation system (E0483) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the High Frequency Chest Wall Oscillation system. You say that the device is medically necessary. The Plan denied your request. The Plan says there are network providers available. The item is not emergent or pre-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 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-approve a High Frequency Chest Wall Oscillation system (E0483) to be provided 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 referral to an out-of-network wound care specialist/podiatrist.
You asked the Plan to pre-approve these services. You say that you have a painful wound. The Plan denied your request. The Plan says the services are available from 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 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 referral to an out-of-network wound care specialist/podiatrist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve an office visit. You say that you are stuck in Georgia and you just want an
annual wellness exam done. The Plan denied your request. The Plan says there are in-network providers
available 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 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
an office visit to be provided 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 core buildup, including any pins when required (D2950) and crown - porcelain/ceramic (D2740) provided February 22, 2021.
You asked the Plan to pay for the core buildup and porcelain/ceramic crown. You say that your dentist was unaware your policy had changed and did not have the correct dental codes for coverage. The Plan denied your request. The Plan says these services are not covered under your benefits.
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 core
buildup, including any pins when required (D2950) and crown - porcelain/ceramic (D2740) provided February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the IV tubing set and infection control supplies rendered on February 26, 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 procedure codes S1015 and S8301 are not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. 

We looked at the file and Medicare rules. Billed procedure codes S1015 (IV tubing extension set) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the IV tubing set and infection control supplies rendered on February 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair and accessories (K0825, E2342, E1028, E1226).

You asked the Plan to pre-approve the group 2 heavy duty power wheelchair and accessories. You say that the heavy-duty power wheelchair is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. A standard group 2 power wheelchair may be considered if requested.

The Plan must follow Medicare rules. Medicare rules say that a Heavy-Duty Power Wheelchair is covered for a beneficiary weighing 285-450 pounds.

We looked at the file and Medicare rules. The record does not show that the enrollee weighs more than 285 pounds. Since coverage criteria for the heavy-duty power wheelchair is not met, the accessories are also non-covered. Based on this information, we decided that Medicare rules for coverage of the group 2 heavy duty power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair and accessories (K0825, E2342, E1028, E1226).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a second unit of localization device placement (10035) provided on February 10, 2021.
You asked the Plan to pay for a second unit of localization device placement. You say that this is separately payable. The Plan denied your request. The Plan says this was previously billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.
We find that a second unit of CPT code 10035 is not supported in the medical record. The medical record only supports one unit of CPT code 10035, which was previously billed on another claim for the same date of service. Based on this information, we decided that Medicare rules for coverage of a second unit of localization device placement have not been met. Therefore, we decided that the Plan does not have to pay for a second unit of localization device placement (10035) provided on February 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteriafor LTACH services.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on February 2, 2021.
You asked the Plan to pay for the outpatient hospital services. You say that The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 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 outpatient hospital services provided on February 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on January 15, 2021.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on January 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675).
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0675) is a preventive service. Claims for E0675 will be denied as not reasonable and necessary. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapy services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network therapy services. You say that the services are medically necessary. The Plan denied your request. The Plan says there are network providers available. The services are not 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve therapy services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on July 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider. The Plan says that there are in-network providers available 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 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 an office visit provided on July 10, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve micrographically oriented histographic surgery (MOHS) (17313, 17314, 14020, and 15220).

You asked the Plan to pre-approve MOHS surgery. You say that the requested MOHS surgery is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested MOHS surgery (17313, 17314, 14020, and 15220).

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 MOHS surgery. Our reviewer says that the enrollee does not meet criteria for the requested MOHS surgery (17313, 17314, 14020, and 15220). Our physician reviewer found the enrollee has a 0.7 cm in size, superficially invasive, well differentiated squamous cell carcinoma of the distal forearm. The lesion is in area L. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MOHS surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve micrographically oriented histographic surgery (MOHS) (17313, 17314, 14020, and 15220).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abutment supported porcelain fused to high noble
metal crown (D6059) for tooth # 31.

You asked the Plan to pre-approve the dental service. You say that your dentist recommended your tooth be
extracted and replaced with an implant as the best possible repair. You say that you feel that this service should
be covered. You say that at the very least, the plan would have had to cover a crown the placement. You also
say that this service should be covered. The Plan denied your request. The Plan says abutment supported
porcelain fused to high noble metal crown is not listed as a covered service.

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 an abutment supported porcelain fused to high noble metal crown (D6059) for tooth # 31.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc.
You asked the Plan to pre-approve Monovisc. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested drug.
The Plan must follow Medicare rules. Medicare rules say that Monovisc is only covered for certain indications. We looked at the file and Medicare rules. Review of the file does not support whether the enrollee will receive other intra-articular (into the joint) injections in the knee during the course of treatment with Monovisc. The documentation does not support if the enrollee has had symptomatic (symptoms such as pain)/functional (such as walking, prolonged standing, or your ability to sleep) improvement from the previous series of injections. The documentation does not support that six months has passed since the enrollee's previous series of injections. Based on this information, we decided that Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Monovisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for guided tissue regeneration (D4266) and an osseous, osteoperiosteal, or cartilage graft (D7950) provided on March 2, 2021.You asked the Plan to pay for the dental services. You say that these services were necessary, and you feel they were billed incorrectly.The Plan denied your request. The Plan says these services are not covered by Medicare or by your 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 guided tissue regeneration (D4266) and an osseous, osteoperiosteal, or cartilage graft (D7950) provided on March 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee x-ray rendered on December 21, 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 73562 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 73562 is radiologic examination, knee; 3 views. We find that CPT code 73562 is not supported in the medical record. Specifically, there is no documentation of a knee x-ray with three views. 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 knee x-ray rendered on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits and treatment with an out-of-network provider.
You asked the Plan to pre-approve the out-of-network office visits and treatment. You say that the pump will need to be replaced and this is the only doctor that will do the replacement. The Plan denied your request. The Plan says an in-network provider is available.
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 office visits and treatment with an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc-One injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy criteria is not met.

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 the injection. Our reviewer says that Our physician reviewer found there is no evidence of a trial and failure of the required drugs. Based on the medical records provided, there is no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.

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 pre-approve a Synvisc-One injection for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for a telemedicine visit provided on December 15, 2020.

You asked the Plan to pay for telemedicine visit. You say that this should be covered by the Plan except for the
copayment. The Plan denied your request. The Plan says that the denial of payment for this service is correct.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not provide any rationale or evidence to support a denial of
payment for this service. Without this, the Plan has not shown that its decision to deny payment for this service
is correct or justified by Medicare rules and your contract with the Plan. Therefore, we decided that the Plan
has to pay for a telemedicine visit provided on December 15, 2020.

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.