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

We decided that the Plan does not have to pre-approve the Vascepa 1 gm capsule medication. 
 
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the enrollee. The Plan denied your request. The Plan says this medication is not a covered benefit under the member's contractual policy. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Vascepa 1 gm capsule medication.  
 
Benefits for this medication 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on July 11, 2019.
You asked the Plan to pay for the office visit. You say that you would like reconsideration because this provider was participating in Medicare in 2019. The Plan denied your request. The Plan says you were reimbursed for prior claims in error.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider opted out of the Medicare program beginning January 1, 2019. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on July 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pay for IRF care. The Plan denied your request. The Plan says IRF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the enrollee is medically stable with no evidence of need for supervision by PMR Physician or needs for acute rehab nursing care. Functionally, given he is at CGA and SBA, he does not require IRF level of therapies. The enrollee may benefit from further physical therapy, but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a commode purchased on February 19, 2020 or a
shower chair purchased on February 24, 2020.
You asked the Plan to reimburse you for the commode or shower chair. You say that these items were required
by your physician and you purchased them from the least expensive supplier you could find. The Plan denied
your request. The Plan says you purchased these items from suppliers not certified by Medicare.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature. Criteria for a commode must be met. No Medicare payment may be made to a
beneficiary for items provided directly by a provider who is not eligible to take Medicare payment.
The items at issue in this appeal were provided by providers not certified by Medicare. Therefore, we decided
that the Plan does not have to reimburse you for the commode purchased on February 19, 2020 or the shower
chair purchased on February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood smear interpretation rendered on January 7, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that no TC is covered for procedure code 85060 when
billed at the hospital.
We looked at the file and Medicare rules. The file shows that procedure code 85060 was billed at an outpatient
hospital place of service; therefore, the TC is not separately payable. 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 blood smear interpretation rendered on January 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee could be treated in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the patient is medically stable with no evidence of need for supervision by a physician or a need for acute rehab nursing care. Functionally, he does not require IRF level of therapies. The patient may benefit from further physical and occupational therapy but he does not require an intensive therapy program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit rendered on February 25, 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 that two or more diagnosis codes are mismatched. 
 
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 states that procedure code 99214 was billed with a mismatched diagnosis code and that it is not appropriate to report unspecified or left and right diagnosis codes when a more specific bilateral code is available; however, the claim does not show that the code was billed with diagnosis codes indicating laterality. Therefore, we decided that the Plan has to pay for the office visit rendered on February 25, 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.
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
September 20, 2019 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. The Plan denied your request. The
Plan says the services were not provided or authorized by designated (network) providers.
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 September 20, 2019 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lesion removal provided on March 11, 2020.
You asked the Plan to waive the copayment for the lesion removal. You say that you haven't been charged an office visit copayment before. You say that you shouldn't be charged now. 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 $20 copayment per visit to a specialist. Covered services include medically necessary medical care or surgery services furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location. You have been asked to pay a $20 copayment for the lesion removal. The lesion removal falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The lesion removal is considered a surgical service that was provided by a specialist. 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 lesion removal provided on March 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Genetic Testing (81120, 81121, 81173, 81201, 81272, 81275, 81310, 81311, 81314, 81321, 81405, 81406, 81210) performed February 12, 2020. 
 
You asked the Plan to pay for the Genetic Testing panel. You say that the services were medically necessary. The Plan denied your request. The Plan says the services should have been billed as a single code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 81120, 81121, 81173, 81201, 81272, 81275, 81310, 81311, 81314, 81321, 81405, 81406, & 81210 are not supported in the medical record. Specifically, per the relevant coverage article, this genetic testing panel should have been billed with the single comprehensive CPT code, 81479. Based on this information, we decided that Medicare rules for coverage of the Genetic Testing panel have not been met. Therefore, we decided that the Plan does not have to pay for Genetic Testing (81120, 81121, 81173, 81201, 81272, 81275, 81310, 81311, 81314, 81321, 81405, 81406, 81210) performed February 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Pin Retention (D2951) provided March 4, 2020.
You asked the Plan to pay for the dental services. You say that you cannot understand why the other service is
covered when the denied service was necessary to complete the other. You feel it should be covered because it
was necessary for the other service. The Plan denied your request. The Plan says this service is not covered
under the plan 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 Pin
Retention (D2951) provided March 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the medical records do not document the severity and symptoms.
The Plan follows Medicare rules. Medicare rules say that endovenous ablation is only covered under certain medical indications. 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 requested services. Our physician reviewer found that the enrollee complains of non-specified fatigue and leg cramps. It is not documented which leg is affected or if condition is bilateral. The enrollee has a very large number of cardiovascular risk factors or other potential etiologies for leg pain including coronary artery disease, dyslipidemia, hypertension, diabetes, arthritis, obesity, and, specifically, peripheral artery disease. No pulse examination is documented. A paraphrased abnormal arterial duplex is documented. Coverage would require that the enrollee have lifestyle limiting symptoms that can be attributed to the veins in question, and be in the absence of significant peripheral artery disease. As the documentation does not meet this criteria, the requested services are not medically reasonable and 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous ablation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for finger surgery (26260) provided on March 9, 2020.
You asked the Plan to waive the copayment for the finger surgery. You say that you would like reconsideration because this service was rendered in the Surgery Center on the bottom floor of the hospital. The Plan denied your request. The Plan says the hospital has verified that you were in an outpatient hospital setting for surgery.
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 $275 copayment for outpatient hospital surgery. You have been asked to pay a $275 copayment for the finger surgery. The finger surgery falls within the outpatient hospital surgery 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 finger surgery (26260) provided on March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, periodic oral evaluation, bitewings, and prophylaxis provided on January 21, 2020 and January 27, 2020 by an OON provider.
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, periodic oral evaluation, bitewings, and prophylaxis. You say that prior to January, this provider was an accepted provider. You also say that you and the provider assumed this provider was in your plan's network. The Plan denied your request. The Plan says the treating provider is OON. The Plan also says that these services are not covered when performed by an OON provider.
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. The records show that you, nor the provider, contacted the Plan prior to receiving the services to confirm the provider's network status. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, periodic oral evaluation, bitewings, and prophylaxis provided on January 21, 2020 and January 27, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not require intensive therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee is ambulatory and tending to activities of daily living with minimal supervision. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance service provided on December 11, 2019.
You asked the Plan to pay for the ambulance service. You say that the service is separately payable. The Plan
denied your request. The Plan says that they will only pay the mileage because the patient was inpatient
hospital status.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. The Plan follows the same rules.
We looked at the file and Medicare rules. The enrollee was outpatient status at the time of transport and the two
hospitals have different provider numbers. Based on this information, we decided that Medicare rules for
coverage of the ambulance service have been met. Therefore, we decided that the Plan has to pay for the
ambulance service provided on December 11, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the services you received on November 26, 2019.
You asked the Plan to waive the coinsurance. You say that you cannot pay this amount. The Plan denied your request. The Plan says you are responsible for the cost share.
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 services provided at an outpatient hospital facility. Review of the file shows that you were provided outpatient hospital services on November 26, 2019. You have been asked to pay a 20% coinsurance for the services, totaling $135.70. The services fall within the outpatient surgery 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 services you received on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5257) purchased on February 6, 2020
from an out of network provider.
You asked the Plan to pay for the hearing aids. You say that the plan representative told you that you had
coverage on hearing instruments up to $2,000 ($1000 per hearing aid) and had emailed you a claim form
following the conversation. The Plan denied your request. The Plan says hearing aids purchased outside of the
vendor network is not covered by the plan.
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 purchased from an in-network provider.
We looked at the 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 (V5257) purchased on February 6, 2020 from an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral
periapical x-ray, bitewings, prophylaxis, resin-based composite, and two amalgams provided on February 6,
2020 by an OON provider.
You asked the Plan to pay for the intraoral periapical x-rays, bitewings, prophylaxis, resin-based composite,
and amalgams. You say that you never received a notice of an assigned dentist. The Plan denied your request.
The Plan says the treating provider is OON with the Plan.
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 first
intraoral periapical x-ray, additional intraoral periapical x-ray, bitewings, prophylaxis, resin-based composite,
and two amalgams provided on February 6, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for gene analysis (prothrombin, coagulation factor II) A variant provided to the enrollee on April 7, 2020. 
 
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 this test is not covered unless you are pregnant. 
 
The Plan must follow Medicare rules. Medicare rules say that the requested testing is only covered for pregnant patients. 
 
The enrollee does not qualify for this testing. 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 gene analysis (prothrombin, coagulation factor II) A variant provided to the enrollee on April 7, 2020.