Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for the enrollee.
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 RFA is covered when specific criteria are met. 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 low back pain with an average pain level of seven to eight out of 10. He had a prior lumbar medial branch block (MBB) that did not report a minimum of 50 percent pain relief. His pain returned less than six months following the procedure. Given that the MBB did not provide at least 50 percent pain relief, the RFA is not reasonable or 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 radiofrequency ablation (RFA) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on December 16, 2019.
You asked the Plan to pay for the prophylaxis. You say that you have to go to the dentist every 3 months because you have periodontal issues. The Plan denied your request. The Plan says this service is covered once every 6 months. The Plan also says that you received a prophylaxis on September 24, 2019.
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, cleanings and are limited to 1 every 6 months. The record shows that you received a prophylaxis on September 24, 2019, and your cleanings benefit was then exhausted for the time period. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on December 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided to the enrollee on December 9, 2019.You asked the Plan to pay for the chest x-ray. The Plan denied your request. The Plan says routine diagnostic testing before surgery, without signs or symptoms indicating a need for the test, is not covered.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 test at issue in this appeal, the chest x-ray, 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 chest x-ray provided to the enrollee on December 9, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says skilled services are not required on a daily basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee's medical status does not require SNF level SN. The enrollee does not have a tracheostomy tube, new enteral feedings, complex wound care or other SNF level skilled nursing need. There are no documents from PT or OT or in the records submitted that reveals the enrollee needs SNF level therapy. The enrollee does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a "daily basis" in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.
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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on September 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the rest home visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 has network providers available who can provide 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 rest home visit provided on September 5, 2019 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 extraction (D7210) provided on October 31, 2019.
You asked the Plan to pay for the extraction. You say that you spoke with the Plan in the middle of October 2019 and asked them to re-enroll you into the Plan. You also say that because this is a new plan you should have 2 additional extractions covered in 2019. The Plan denied your request. The Plan says the benefits for this service have been satisfied and the frequency limitation has been exceeded. The Plan also says that because you were enrolled in the Plan at the time of the first 4 extractions, these processed toward your benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, extractions are limited to two procedures per calendar year. The record shows that you received four extractions (D7140) on January 9, 2019 and your extractions benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the extraction (D7210) provided on October 31, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Emgality.
You asked the Plan to pre-approve Emgality. You say that the enrollee needs Emgality for migraines. The Plan denied your request. The Plan says this drug is not a Medicare Part B drug.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Emgality.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ultrasound provided by on November 12, 2019.You asked the Plan to waive the copayment foran ultrasound. You say that you disagree with the denial of 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 $100 copayment for radiological diagnostic services. You have been asked to pay the allowed amount of $46.56, which is less than the $100 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This meansthat 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 foran ultrasound provided by on November 12, 2019
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Prolia. You asked the Plan to pre-approve Prolia. You say that alternative drugs have been tried/failed. The Plan denied your request. The Plan says the denial of authorization for Prolia is correct, because the Plan requires a trial of zoledronic acid before it will cover Prolia. Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Prolia. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drug of zoledronic acid. The documentation does not support that zoledronic acid would likely be less effective and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on November 13, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no network deficiency for these services and alternate network providers are available.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 has network providers available who can provide 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 foran office visit provided on November 13, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 23, 2019.
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 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on April 10, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
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 services was not filed until November 22, 2019. 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 services provided on April 10, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), bitewing x-rays (D0274), the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the adjunctive pre-diagnostic testing(D0431) provided on August 1, 2019 by an out of network provider.You asked the Plan to pay for the dental services. You say that you have been seeing this provider for years and have never had a problem. You say that you should not have to switch providers because they are no longer in network with your plan. You also say that the Plan should pay for the services.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says dental care is only covered for in network providers. The Plan also says that you did not contact the Plan prior to receiving the services.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 dental services you received are not covered when you received them out of network.Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), bitewing x-rays (D0274), the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the adjunctive pre-diagnostic testing (D0431) provided on August 1,2019 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for automatic external defibrillator, with integrated electrocardiogram analysis, garment type (K0606) provided on October 24,2019 by an in-network provider.You asked the Plan to waive the coinsurance for the DME. You say that you were told at the hospital that the equipment would not cost you anything and Medicare would pay for it.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received an automatic external defibrillator, with integrated electrocardiogram analysis, garment type (K0606) provided on October 24, 2019 by an in-network provider. You are asked to pay 20% coinsurance for the DME. The provider has confirmed an adjustment has been made on your account and statement to reflect correctly $700 patient responsibility. 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 automatic external defibrillator, with integrated electrocardiogram analysis, garment type (K0606) provided on October 24, 2019 by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair.
You asked the Plan to pay for a shower chair. You say that you had an authorized surgery which required you to not sit for four to six weeks in water or risk infection. You say that you still couldn't stand because your legs and body were weak and therefore you needed to sit on the chair in the shower. You say that you are having therapy to regain your strength. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a shower chair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of physical therapy (PT) services (97139).
You asked the Plan to pre-approve the continuation of PT services. 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 must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 continuation of PT services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found for shoulder pain, PT is generally accepted as specific and effective therapy. Goals include reducing pain, restoring function, and educating regarding a home exercise program (HEP) prior to transition towards a home program. In this case, there is no indication prior PT has served to provide sustained, significant improvement in pain and/or function and there is no indication residual deficits could not be addressed via a home exercise 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 the continuation of PT services have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of physical therapy (PT) services (97139).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forvehicle modification, hand controls and lessons to learn to use these modifications (E1399) provided on October 22, 2019.You asked the Plan to pay forvehicle modification, hand controls and lessons to learn to use these modifications.You say that you have multiple sclerosis and your legs are getting weaker and you are having more difficulty driving.The Plan denied your request. The Plan says the requested services is not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pay forvehicle modification, hand controls and lessons to learn to use these modifications (E1399) provided on October 22, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a follow-up office visit provided on August 28, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a follow-up office visit. You say that this was a follow-up appointment and was necessary. The Plan denied your request. The Plan says no prior authorization was 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 has network providers available who can provide 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 a follow-up office visit provided on August 28, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the nursing home is responsible to obtain prior authorization. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 9, 2019 by an out of network (OON) provider.