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

We decided that the Plan does not have to pre-approve a referral for an office visit to get foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve a referral for an office visit to get foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept intraosseous nerve ablation procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that it is felt that this procedure is medically necessary. The Plan denied your request. The Plan says this remains an investigational procedure.
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 the Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation, including the magnetic resonance imaging (MRI) show multiple plausible pain generators including at the lumbosacral spine. There is plausible pain from facet arthrosis and spinal stenosis. Also, he reports his last bilateral L4 and L5 transforaminal epidural steroid injection (on 3/4/21) lasted about 5 months and is now experiencing increased pain again. With such significant benefit (noted to be 100%) with the previously administered transforaminal epidural steroid injection; rationale to proceed with a more invasive procedure is not evident. Detailed documentation is not evident regarding the chronic low back pain generators clearly delineated as
being linked to the spinal vertebral body(s) in origin. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Intracept procedure at L3-L5 is 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 the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept intraosseous nerve ablation procedure
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral periapical first radiographic images (D0220 and D0230) provided on June 15, 2021.
You asked the Plan to pay for the intraoral periapical first radiographic images. You say that you would like reconsideration because you were seen on an emergency basis for an infection involving your teeth. The Plan denied your request. The Plan says these services exceed the bitewing 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 intraoral periapical first radiographic images (D0220 and D0230) provided on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
August 2, 2021.
You asked the Plan to pay for the dental service. You say that you went to see a new dentist as you were not
happy with the previous dental office. You also say that this visit should be covered. The Plan denied your
request. The Plan says 1 comprehensive oral evaluation is covered every 3 years. The Plan also says that the
frequency limit 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 and the services is listed as covered, the
frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation
that you received on March 5, 2020, and June 11, 2021. The record also shows that the Plan already made a one-time exception to cover this service and payment cannot be made. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213), the initial preventive physical examination (G0402), and the electrocardiogram (G0403) rendered by the out-of-network (OON) provider on August 2, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 office visit (99213), the initial preventive physical examination (G0402), and the electrocardiogram (G0403) rendered by the out-of-network (OON) provider on August 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Inogen portable oxygen concentrator.
You asked the Plan to pre-approve the portable oxygen concentrator. You say that you feel that this is medially necessary as you become short of breath while walking. The Plan denied your request. The Plan says you do not meet the criteria for coverage of this oxygen concentrator.
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen. 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 portable oxygen concentrator. Our reviewer says that the documentation does not support that oxygen supplementation is medically necessary for this enrollee. Our physician reviewer found the enrollee is an 89-year-old man with chronic obstructive pulmonary disease, chronic respiratory failure, and pulmonary hypertension. The enrollee's oxygen saturation before walking was 99% and dropped to 91% 6 minutes into walking. He reported shortness of breath and dizziness. After sitting for 5 minutes, his room air oxygen saturation was 97%. The documentation does not include oxygen saturation levels that meet the coverage criteria in this case. There is no additional clinical evidence in the file that would support that oxygen is medically necessary despite oxygen saturations of over 89% 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 portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve the Inogen portable oxygen concentrator
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid provided on October 27, 2020 and the conformity evaluation provided on November 2, 2020.
You asked the Plan to pay for the hearing aid and conformity evaluation. The Plan denied your request. The Plan says there is no coverage if hearing aids, or related services are received from an out-of-network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids and related services only from an in-network provider. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid and conformity evaluation have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid provided on October 27, 2020 and the conformity evaluation provided on November 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (81546) rendered by the out-of-network (OON) provider on July 21, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the laboratory service (81546) rendered by the out-of-network (OON) provider on
July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a hearing aid provided on March 4, 2020.
You asked the Plan to reimburse you for a hearing aid. You say that the hearing aid should not be considered under the routine hearing benefit as this was required to as an enhancement to your Cochlear implants for hearing quality in your left ear. The Plan denied your request. The Plan says that the member's benefit pays for hearing aids only when provided by the Plan's hearing aid provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when received from the Plan's hearing aid provider. We looked at the file and the Plan's rules. The file shows that the hearing aid was not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of a hearing aid have not been met. Therefore, we decided that the Plan does not have to reimburse you for a hearing aid provided on March 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reverse total shoulder arthroplasty.
You asked the Plan to pre-approve a reverse total shoulder arthroplasty. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 a reverse total shoulder arthroplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of the degree of disability or failure of conservative treatment measures. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 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 reverse total shoulder arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a reverse total shoulder arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tub stool.
You asked the Plan to pre-approve a tub stool. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not primarily medical in nature.
The Plan must follow Medicare rules. Medicare rules say that tub stools are not covered because they are not primarily medical in nature. While a tub stool 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 pre-approve a tub stool.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for fibromyalgia testing (83520, 88346, 88350, 88516, 86332, 86353, 88185, 86356, 86359, 88112, 88184, 88230, 88240, 88241) provided on October 24, 2020.
You asked the Plan to pay for fibromyalgia testing. You say that this was medically necessary. The Plan denied your request. The Plan says this has not been shown to have clinical utility.
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 fibromyalgia testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical utility of fibromyalgia testing has not been demonstrated. More research is needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of fibromyalgia testing have not been met. Therefore, we decided that the Plan does not have to pay for fibromyalgia testing (83520, 88346, 88350, 88516, 86332, 86353, 88185, 86356, 86359, 88112, 88184, 88230, 88240, 88241) provided on October 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214), ophthalmic biometry (92136), imaging (92134), cataract removal (66984) and anesthesia (00142) provided on March 2, 2021 to March 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the ophthalmology services. You say that you would like reconsideration because the services were medically necessary. The Plan denied your request. The Plan says no authorization was requested or obtained for the out-of-network 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 the office visit (99214), ophthalmic biometry (92136), imaging (92134), cataract removal (66984) and anesthesia (00142) provided on March 2, 2021 to March 9, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on March 11, 2021.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the code is not appropriate for the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on March 11, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on July 15, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on
July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening digital breast tomosynthesis, bilateral (77063) and the screening mammography, including computer-aided detection (CAD) (77067) rendered by the out-of-network (OON) provider on May 24, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 screening digital breast tomosynthesis, bilateral (77063) and the screening mammography, including computer-aided detection (CAD) (77067) rendered by the out-of-network (OON) provider on May 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra-wide/heavy-duty commode chair.
You asked the Plan to pre-approve the commode. You say that this is medically necessary. The Plan denied your request. The Plan says the regular commode that was supplied on 9/28/21 is a functional alternative.
The Plan must follow Medicare rules. The rules say that an extra wide/heavy duty commode chair (E0168) is covered for a beneficiary who weighs 300 pounds or more. The records show that your weight is 135 pounds. You must weigh 300 pounds or more to qualify for this request. Based on this information, we decided that Medicare rules for coverage of the commode have not been met. Therefore, we decided that the Plan does not have to pre-approve an extra-wide/heavy-duty commode chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device with an out-of-network provider.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this can be provided with the contracted vendor.
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. The plan has stated that the device would be covered when provided by the contracted vendor. 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 high frequency chest wall oscillation device with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99202), the Moh's surgery (17311, 17312), and the adjacent tissue transfer or rearrangement of the eyelids, nose, ears and/or lips (14061) rendered by the out-of-network (OON) provider on December 10, 2020 and December 22, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 office visit (99202), the Moh's surgery (17311, 17312), and the adjacent tissue transfer or rearrangement of the eyelids, nose, ears and/or lips (14061) rendered by the out-of-network (OON) provider on December 10, 2020 and December 22, 2020.