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

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE) with Doppler.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has no new cardiac symptoms of chest pain, palpitations or dyspnea based in the provided notes. She had echocardiograms done in 2016, 2017, and March of 2020 that showed preserved and unchanged left ventricular (LV) function with only mild mitral insufficiency. There were no murmurs on exam at the time of the last exam and the cardiopulmonary examination done in March of 2020 was reported as normal. There are no further more recent medical notes provided reporting any recent changes in symptoms or signs on exam. Given the multiple prior echocardiograms with normal LV function, including one in the past year, along with the absence of new symptoms or signs of cardiovascular disease, a repeat transthoracic echocardiogram is not medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE) with Doppler.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) provided on July 1, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the chiropractor services. You say that you don't have the money. You never got a claim in 3 years. You pay every month. The doctor sent the bill that had to paid. You are a poor senior. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 chiropractic manipulative treatment (98940) provided on July 1, 2020 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 complete lower denture (D5120).

You asked the Plan to pay for the dental services. You say that you received your first set of dentures from another provider. You say that they did not fit properly. You say that you went back for multiple adjustments. You say that every time you went back, you were told "bottom dentures always move." You say that you went to a different provider for this denture. You also say that he would not adjust dentures from another provider, so you needed to get a new one. The Plan denied your request. The Plan says 1 set of dentures is covered every 5 years. The Plan also says that the frequency limit for this service has been exceeded.

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 frequency limit of 1 set every 5 years has been exceeded. The record shows that the Plan paid for dentures that you received. Therefore, we decided that the Plan does not have to pay for the complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular partial denture (D5212) and tooth extraction (D7210).

You asked the Plan to pay for the dental services. You say that you were told there would not be a copayment and you cannot afford the bill. The Plan denied your request. The Plan says normally these services are covered, however, you reached your annual maximum $1,500 allowance on the date of service. The Plan paid out the remainder of this allowance; however, the remaining cost for these services is your responsibility.

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. Specifically, the Plan will not cover dental services beyond the $1,500 outlined in the contract. Documentation was provided that showed that on the date of service, the Plan had already paid $1,054.06 for your dental care earlier in the year. For the claim in question, the Plan paid out the remaining $445.94 ($1,500 - $1,054.06 = $445.94) of your allowance, but you are responsible for any cost beyond the $1,500 for the year. Therefore, we decided that the Plan does not have to pay for the mandibular partial denture (D5212) and tooth extraction (D7210).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 15, 2019.
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 services were billed untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the laboratory services was not filed until October 30, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance.

You asked the Plan to pay for the periodontal maintenance. You say that the plan should cover the difference between the cost of a periodontal service and the covered prophylaxis. The Plan denied your request. The Plan says periodontal maintenance is not included in your supplemental 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 the periodontal maintenance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostate artery embolization. You asked the Plan to pre-approve prostate artery embolization. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because prostate artery embolization is 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 prostate artery embolization. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current guidelines state that prostate artery embolization for treatment of the enrollee's condition is not supported by current data and trial designs, the benefit over risk remains unclear; therefore, this is not recommended outside of the context of clinical trials. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of prostate artery embolization have not been met. Therefore, we decided that the Plan does not have to pre-approve prostate artery embolization.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture (D5213).
You asked the Plan to pre-approve the dental item. You say that the enrollee lost her denture while she was
having medical issues. You also say that the enrollee has lost weight since because it is difficult for her to chew
without it. The Plan denied your request. The Plan says upper partial dentures are covered once every 5 plan
years. The Plan also says that the frequency limit has been reached.
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 frequency limit of 1 upper denture
every 5 plan years has been reached. The record shows that the Plan paid for an upper denture that you received
on February 2, 2019. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture
(D5213).
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 congestive heart failure and NSTEMI. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammography services coded 77067 provided on October 27, 2020.
You asked the Plan to pay for the screening mammography services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 77067 is screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed. We find that CPT code 77067 is not supported in the medical record. Specifically, a screening mammography is a radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection of breast cancer, and includes a physician's interpretation of the results of the procedure. A diagnostic mammography is a radiological procedure to a man or woman with signs and symptoms of breast disease or a personal history of breast cancer, personal history of biopsy proven benign breast disease and includes a physician's interpretation of the results of the procedure. The documentation shows that the enrollee has a personal history of breast cancer. This means that this service was not provided for screening purposes. Based on this information, we decided that Medicare rules for coverage of the screening mammography services have not been met. Therefore, we decided that the Plan does not have to pay for the screening mammography services coded 77067 provided on October 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered on October 2, 2020.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was 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 $50 copayment for lab services at an outpatient hospital.
Review of the file shows that you received laboratory services at an outpatient hospital on October 2, 2020. Per the contract with the Plan, there is a $50 copayment for lab services at an outpatient hospital. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $32.91. Given that the allowed amount was less than the $50 copayment, you have been asked to pay $32.91 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the laboratory services rendered on October 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for lenses, single vision plano (V2100) anti-reflective coating (V2750) vision services, frames (V2020) purchased June 29, 2020.
You asked the Plan to pay for the vision services. You say that your eyeglasses annual allowance of $125 was declined with 4 reasons on the declined statement. 06/29/20 is your only routine eye exam and purchase of one pair of eyeglasses this year. The Plan denied your request. The Plan says the maximum amount of $125 was covered and paid for this service
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 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 any amount over the $125 eye wear benefit. We looked at the file and the Plan's rules. You have to pay any amount over the $125 eye wear benefit. The plan had paid the maximum amount of $125 for this service. The vision services fall within the Vision care 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 pay for lenses, single vision plano (V2100) anti-reflective coating (V2750) vision services, frames (V2020) purchased June 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device (E0601) and a humidifier (E0562) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a CPAP device and a humidifier. You say that the enrollee needs this device. The Plan denied your request. The Plan says this is available from in-network suppliers.
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 continuous positive airway pressure (CPAP) device (E0601) and a humidifier (E0562) 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 pay for home health telemedicine physician services provided on September 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for home health telemedicine physician services. You say that prior authorization is not required for the services that were provider. The Plan denied your request. The Plan says prior authorization is required when services are provided by an out-of-network provider. The Plan says that a participating provider did not refer 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 home health telemedicine physician services provided on September 29, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for screening mammography services (77063, 77067).

You asked the Plan to pay for screening mammography services. You say that these services should be covered. The Plan denied your request. The Plan says these services were not billed correctly.

Medicare rules say that all Indian Health Services (IHS) charges, except for the exceptions listed above, are combined and reported under revenue code 0510 (clinic visit) on TOB 13X (hospital outpatient).

We looked at the file and Medicare rules. The services at issue were not reported under revenue code 0510. Based on this information, we decided that Medicare rules for coverage of screening mammography services have not been met. Therefore, we decided that the Plan does not have to pay for screening mammography services (77063, 77067).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 24, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurolysis facet nerve (64635-65636)
You asked the Plan to pre-approve neurolysis facet nerve. You say that back surgery was deemed unnecessary by surgeons because it was deemed more appropriate to have less invasive and less costly facet nerve destruction. The Plan denied your request. The Plan says the records do not support that this procedure is 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 neurolysis facet nerve. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain with scoliosis. He is s/p L4-L5 laminectomy, has had a caudal epidural steroid injection which did not relieve his pain, takes Tylenol daily for pain and is doing a home exercise program. He had trial MBBs but did not have pain relief for a week. It is not clear if the diagnostic blocks actually provided significant pain relief. Therefore, the request is deemed not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neurolysis facet nerve have not been met. Therefore, we decided that the Plan does not have to pre-approve neurolysis facet nerve (64635-65636)
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the esophagogastroduodenoscopy (EGD) services.

You asked the Plan to waive the copay for the services provided. You say that you never signed anything saying you were having surgery. The Plan denied your request. The Plan says the claim processed 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 $400 copay for outpatient surgery.

The medical records provided showed that you received an EGD with biopsy. This is a surgical procedure. You have been asked to pay a $400 copay for the services provided. 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 copay for the esophagogastroduodenoscopy (EGD) services.