Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), tomographic survey (D0322), and intraoral - complete series of radiographic images (D0210).

You asked the Plan to pay for the panoramic x-rays, tomographic survey, and intraoral x-rays You say that the cost of the services is a financial burden. The Plan denied your request. The Plan says you received services from an opt-out provider and therefore they 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. The Plan covers the panoramic x-rays, tomographic survey, and intraoral x-rays when you see a licensed dental provider who has not opted out of Original Medicare.

We looked at file and Medicare rules. The request is for services which were provided by a dentist who has opted out of Medicare. Based on this information, we decided that the Plan's rules for coverage of the panoramic x-rays, tomographic survey, and intraoral x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330), tomographic survey (D0322), and intraoral - complete series of radiographic images (D0210).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Omnipod insulin delivery system for the enrollee.
You asked the Plan to pre-approve the Omnipod insulin system. 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. Medicare rules say that disposable drug delivery systems, such as the
Omnipod, are not covered by Medicare Part B as they do not meet the definition of durable medical equipment.
Although this may be appropriate for the enrollee, neither Medicare nor the Plan covers this device. Therefore,
we decided that the Plan does not have to pre-approve an Omnipod insulin delivery system for the enrollee.
Benefits for the Omnipod insulin system 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an endoscopic decompression surgery (62380).

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services provided were investigational and are not covered under Medicare.

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 surgical services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the endoscopic multilevel Rhizotomy procedure and endoscopic lumbar decompression remain experimental. More research is needed to show safety and efficacy of the procedure.

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 surgical services have not been met. Therefore, we decided that the Plan does not have to pay for an endoscopic decompression surgery (62380).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services.

You asked the Plan to pay for the ambulance service. You say that the transport was medically necessary for an evaluation. The Plan denied your request. The Plan says ambulance transportation was not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

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 ambulance service. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found the review has determined that the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this patient. The documentation did not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The documentation did not support that the ambulance transport was medically reasonable and necessary for the patient.

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 ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment 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 this was ordered via telemedicine.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.

A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for durable medical equipment provided to the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the CT scan and MRI.

You asked the Plan to reduce the copayment for the CT scan and MRI. You say that you were informed there would only one copayment. The Plan denied your request. The Plan says the copayments 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 $225 copayment for all other diagnostic and nuclear medicine radiological services. If multiple test types (such as CT and PET) are performed in the same day, multiple copayments will apply.

You have been asked to pay a total of $423.52 for the CT scan and MRI.

The CT scan and MRI fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Evidence of Coverage states multiple copayments will apply if multiple tests are performed. 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 reduce the copayment for the CT scan and MRI.
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 these services are medically necessary. The Plan
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a
lower level of care.
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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for surgical management of a L4
compression fracture after a fall. Your medical problems are stable. There are no complex nursing or
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation
services. Medically necessary care can be provided in a different level of care. There is not a reasonable
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria
for IRF 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided by an out of network (OON) provider.

You asked the Plan to pay for pathology services. You say that you would like this claim reprocessed and paid. You say that these services were referred to you. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 pathology services provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

You asked the Plan to pay for the laboratory 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 a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The laboratory test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis.

You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically
necessary. The Plan denied your request. The Plan says at the time of review the Plan was unable to discover
any evidence of an established relationship between the enrollee and the ordering physician.

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 lumbar-sacral orthosis (L0650). Our
reviewer says that the orthosis is not medically necessary. Our physician reviewer found the available
documentation in the case file does not support that the requested lumbar-sacral orthosis was medically
reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the
LCD. 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 an appropriate evaluation of the enrollee and insufficient documentation
of a credible physical examination of the back.

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 (L0650) have been met. Therefore, we decided that
the Plan does not have to pay for the lumbar-sacral orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chronic care management services provided by an out-of-network provider.

You asked the Plan to pay for chronic care management services. You say that there is a medical necessity pre-established to provide services to patients needing care. You say that the claim should be processed for reimbursement. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider.

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 chronic care management services provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.

You asked the Plan to pay for physician services. 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 the member's primary care physician.

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 physician services provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF services. You say that you are not receiving the physical therapy needed to recover and go home. The Plan denied your request. The Plan says as of February 20, 2021 you have used all of the skilled nursing facility days that are covered under your Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from October 20, 2020, through November 26, 2020, December 18, 2020, through January 4, 2022, and January 3, 2021, through February 20, 2021. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The Plan says that they have paid for 104 days of SNF services during this benefit period. The Plan says they will not retract these additional four days. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee's needs could be met at a lower level of care.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found while the patient's condition necessitated further evaluation, it did not result in the enrollee spending two midnights in the hospital. Records do not support inpatient 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.

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 physician's services. 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 physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services for a consultation and two follow-up visits to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physician's services for a consultation and two follow-up visits to be provided by the out-of-network provider. The Plan denied your request. The Plan says you can be safely transitioned with our in-network provide. The health plan agrees to approve a one-time follow up visit with and upholds the denial of the consultation and the other two follow up visits 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 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 physician's services for a consultation and two follow-up visits to be provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns, a prefabricated post and core in addition to crown, and endodontic therapy.
You asked the Plan to pre-approve the crowns, prefabricated post and core, and endodontic therapy. You say that you would like these services to be approved for coverage because they are necessary. The Plan denied your request. The Plan says these 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 pre-approve crowns, a prefabricated post and core in addition to crown, and endodontic therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for immediate denture - maxillary (D5130) and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided from February 4, 2020 through March 11, 2020 by a non-contracted dental provider.
You asked the Plan to pay for the dental services. You say that you are entitled to full reimbursement based on being retired. The Plan denied your request. The Plan says your Plan does not have any dental benefits beyond the stated coverage for Medicare-covered dental services and $250 maximum allowance for non-Medicare dental services. The Plan states that you would need to contact your retiree group administrators to determine if further reimbursement can be made from sources outside the Health Plan 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. You received non-Medicare covered dental services, D5130 and D7140. Your EOC clearly states that the Health Plan will reimburse the enrollee $250 maximum allowance for non-Medicare covered dental services. The Health Plan can only process your claims based on the coverage stated in your plan benefit documents. The Health Plan has reimbursed you $250 via check issued March 30, 2020. The Health Plan will continue to deny your request for additional reimbursement as you have been reimbursed to the maximum allowance of $250 for non-Medicare covered dental services under your Plan benefit. Therefore, we decided that the Plan does not have to pay for immediate denture - maxillary (D5130) and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided from February 4, 2020 through March 11, 2020 by a non-contracted dental provider.