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

We decided that the Plan does not have to pay for an LSO (L0650) provided on August 31, 2020.
You asked the Plan to pay for an LSO. You say that the enrollee is using the requested medically necessary item with benefit. The Plan denied your request. The Plan says rules for payment have not been met because there were no medical records provided to show the prescribing physician ever saw 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 pay for an LSO. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation of recent injury or surgery. There is no documentation that the physician has confirmed that pain is reduced by immobility or that there is a deformed spine or weak spinal muscles. The elements of the Medicare guidelines are not satisfied. The requested item 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 an LSO have not been met. Therefore, we decided that the Plan does not have to pay for an LSO (L0650) provided on August 31, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan does not have to pre-approve more than 1 set of Medial Branch Block injections (64636, 64635).
You asked the Plan to pre-approve more than 1 set of injections. You say that the repeat injections, an additional set of injections and radiofrequency ablation are medically necessary. The Plan denied your request. The Plan says these services are not medically necessary.
Our reviewer found that one set of Medial Branch Block injections is appropriate for diagnostic purposes.
Our reviewer also found that additional injections and radiofrequency ablations are not medically necessary at this time. Repeat procedures are not medically necessary unless it is determined that the diagnostic Medial Branch Blocks provided at least 80% pain relief.
Therefore, we decided that the Plan must approve 1 set of Medial Branch Block injections, however, the additional injections and ablation do not need to be approved at this time.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0120), bitewing x-rays (D0274) and
dental cleaning (D1110) provided on November 18, 2020, by an OON provider.
You asked the Plan to pay for the dental services. You say that you did not realize this provider was not in the
Plan's network anymore. The Plan denied your request. The Plan says it is the responsibility of the member to
verify the network status of their chosen providers. The Plan states that their records show that you did not
contact the Plan to verify the network status of this provider prior to services. This provider has opted out of
Medicare and does not accept any Medicare payments.
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 oral
evaluation (D0120), bitewing x-rays (D0274) and dental cleaning (D1110) provided on November 18, 2020, by
an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the removal of a central venous catheter provided on November 2, 2020.
You asked the Plan to waive the copayment for the removal of a central venous catheter. You say that the provider was unable to successfully remove the device the first time so you should not be responsible for the charges. 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 $400 copayment for outpatient surgery, including services provided at hospital outpatient facilities. You have been asked to pay a $400 copayment for the removal of a central venous catheter. The removal of a central venous catheter falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 the removal of a central venous catheter provided on November 2, 2020.
We note your complaint that the provider was unable to successfully complete the procedure the first time. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal examination (D0180), periodontal scaling and root planing (D4341), localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381), gingival irrigation - per quadrant (D4921), and unspecified periodontal procedure (D4999) provided December 7, 2020.
You asked the Plan to pay for the comprehensive periodontal examination, periodontal scaling and root planing, delivery of antimicrobial agents, gingival irrigation, and unspecified periodontal procedure. You say that you feel like you are being punished for receiving necessary care. The Plan denied your request. The Plan says the services are not covered under your dental 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal examination (D0180), periodontal scaling and root planing (D4341), localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381), gingival irrigation - per quadrant (D4921), and unspecified periodontal procedure (D4999) provided December 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81479) provided on October 1, 2020.
You asked the Plan to pay for laboratory services. You say that this should be covered. The Plan denied your request. The Plan says required documentation has not been submitted.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We find that CPT code 81479 is not supported in the medical record. Specifically, medical records showing this code was ordered and performed have not been submitted. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81479) provided on October 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided on November 2, 2020.
You asked the Plan to waive the copayment for an x-ray. You say that you cannot afford the charges. 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 $110
copayment for basic radiological services provided at an outpatient hospital facility.
You have been asked to pay a $110 copayment for an x-ray. An x-ray falls within the outpatient hospital
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 an x-ray provided on
November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction you had on November 5, 2020.
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says this is not a covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided as part of a routine vision exam. We looked at the file and the Plan's rules. The requested eye refraction was provided during a Medicare-covered eye exam. The Plan only covers refractions provided during routine eye exams. This was not a routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction you had on November 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient services for the elective total hip arthroplasty.
You asked the Plan to pre-approve inpatient services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 inpatient services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The procedure is currently approved as an ambulatory procedure. There is no clinical rationale for the requested inpatient admission. Therefore, the enrollee does not meet criteria for the requested inpatient 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 inpatient services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient services for the elective total hip arthroplasty.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on July 26, 2020 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says the service was rendered by an OON provider. The Plan also says that prior authorization was not obtained.
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 the subsequent nursing facility care provided on July 26, 2020 by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study.
You asked the Plan to pre-approve a sleep study. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that PSG, HST, and MSLT are not covered under certain circumstances. 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 a sleep study. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case; the record does not indicate that the enrollee has obstructive sleep apnea. The criteria of the local coverage determination are not satisfied, and 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 a sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study.
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 you would like reconsideration because the member will benefit from acute rehab to optimize his level of function prior to returning home. The Plan denied your request. The Plan says the member does not require intensive therapy program on an inpatient rehab unit.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare 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 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 member does not have any complex nursing or rehabilitation needs. There is not a reasonable expectation that the member will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on September 10, 2020, by
an OON provider.
You asked the Plan to pay for skilled nursing services. You say that the provider is part of a physician group
who provides services in good faith. You say that you would like this claim reprocessed and paid. The Plan
denied your request. The Plan says prior authorization was not obtained.
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 skilled nursing services provided on September
10, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an annual wellness visit (G0439) provided on November 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an OON annual wellness visit. You say that you have a right to go to a primary care provider of your choice. The Plan denied your request. The Plan says your contract specifies that you must receive care 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 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 annual wellness visit (G0439) provided on November 20, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve plastic surgery services to be provided by an OON
provider.
You asked the Plan to pre-approve plastic surgery services. You say that you would like the Plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent
to seek out-of-network care. The Plan says there are in-network plastic surgeons available to the enrollee that
can provide the services being requested.
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
plastic surgery services to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on September 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say for certain services, you or your provider will need to get approval from the plan before the Plan can cover the service. The requested surgery services require prior authorization for coverage by the Plan. The records do not show that the services were pre-approved by the Plan. 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 surgery services provided on September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 30, 2020.
You asked the Plan to pay for the dental service. You say that you feel that you should not owe this money. You also say that you were not aware that this service would not be covered. The Plan denied your request. The Plan says there is a $2,000 allowance for covered dental services. The Plan also says that the allowance has been exhausted prior to receiving the dental service in this case.
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 $2,000 allowance has been exceeded. The record shows that the Plan has paid $2,000 toward dental services that you have received prior to processing this claim. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the scooter provided on August 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the scooter. You say that you would like reconsideration because this scooter was needed urgently and is a financial burden. The Plan denied your request. The Plan says this provider is not contracted with the Plan and approval was not obtained prior to purchasing this equipment.
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 scooter provided on August 11, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Onetouch ultra blue test strips.
You asked the Plan to pre-approve Onetouch ultra blue test strips. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers as long as the enrollee retains access to all medically necessary items (including non-preferred brands). 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 Onetouch ultra blue test strips. Our reviewer says that the items are not medically necessary. Our physician reviewer found there is insufficient data here to indicate that using the accuchek meter and strips would not enable this enrollee to monitor his blood glucose levels adequately and that he needs the Onetouch strips since he has 3-meter sand keeps them in various locations. We are not told why he could not use the accu chek meter in his home, in his car and in his lake house. Hence criteria for coverage of Onetouch strips is not provided. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Onetouch ultra blue test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Onetouch ultra blue test strips.