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

We decided that the Plan does not have to waive the copayment for destruction by neurolytic agent, paravertebral facet joint nerve, lumbar or sacral, single facet joint (64635) provided May 12, 2021.
You asked the Plan to waive the copayment for the pain management services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says this service was processed with the correct copayment applied per the Evidence of Coverage.
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 $25 copayment for in-network specialist's office. 
You have been asked to pay $25 copayment for the pain management services. The pain management services fall within the Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for destruction by neurolytic agent, paravertebral facet joint nerve, lumbar or sacral, single facet joint (64635) provided May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Device for the enrollee.
You asked the Plan to pre-approve these services. You say that this is needed to treat the enrollee's lumbar spinal stenosis with neurogenic claudication. The Plan denied your request. The Plan says that experimental and investigational procedures are not covered by 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 pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided June 20, 2020 to June 22,
2020.
You asked the Plan to pay for the inpatient hospital care. You say that DRG 872 was appropriately billed. The
Plan denied your request. The Plan says DRG 392 was more appropriate for the services at issue.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with DRG 872, septicemia or severe sepsis. 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 inpatient hospital care. Our reviewer says that DRG
872 is not supported in the records. Our physician reviewer found there was a lack of objective clinical
evidence in the records to support the diagnosis of sepsis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital care provided June 20, 2020 to June 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on August 18, 2019.

You asked the Plan to pay for the subsequent hospital care provided on August 18, 2019. You say that the claim was billed within the guidelines. The Plan denied your request. The Plan says that claims received 12 months or 1 calendar year after the date of service will be denied. The Plan says that the claim was received outside of the allowed 12-month timeframe.

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 subsequent hospital care provided on August 18, 2019, was not filed until April 21, 2021. 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 subsequent hospital care provided on August 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on September 2, 2021 with a pubic ramus fracture after a fall. She did not require surgery. The physical and occupational therapy notes state she needs minimal to modified assist with standing up and minimal assist to lie down and do chair-to-bed transfers. She is not shown to require or to be able to currently tolerate/perform, 15 hours per week of rehabilitative services with regular physician evaluation. The IRF services are 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 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 the services provided by an out-of-network provider on May 25, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 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 services provided by an out-of-network provider on May 25, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to hold you harmless for the non-covered inpatient services (A9270) provided from March 29, 2021, to March 31, 2021.
You asked the Plan to hold you harmless for the inpatient services. You say that these services were necessary, and you do not understand why they are not being covered by the Plan. The Plan denied your request. The Plan says that these services are not covered by Medicare and are your responsibility.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the inpatient services by a contract provider. The file does not show that the Plan provided notice that the inpatient services would not be covered. Under Medicare rules, this means the inpatient services are considered approved by the Plan. Because these services are not covered by Medicare, we cannot ask the Plan to pay for them. However, the Plan cannot ask you to pay for services which were provided as part of your inpatient services received from an in-network provider without notice that they would not be covered. Therefore, we decided that the Plan has to hold you harmless for the non-covered inpatient services (A9270) provided from March 29, 2021, to March 31, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns - porcelain fused to high noble metal (D2750)
provided March 3, 2021.

You asked the Plan to pay for the crowns. You say that the estimated price increased significantly, and you
would like the claim reviewed. The Plan denied your request. The Plan says the Plan has provided coverage up
to the $3,000 dental allowance and no further payment is due.

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 crowns up
to the Plan's $3,000 combined allowance for supplemental preventative and comprehensive dental services
every year.

We looked at the file and Medicare rules. The Plan provided documentation showing that the full $3,000 dental
allowance was applied toward the claim. You are responsible for the remaining amount over the dental
allowance. Therefore, we decided that the Plan does not have to pay for the crowns - porcelain fused to high
noble metal (D2750) provided March 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 lumbar spinal stenosis. The requested Superion spacer is considered experimental in nature, as more research is needed to show safety and efficacy. The services are therefore 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 a Vertiflex Superion spacer
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe
gingival inflammation (D4346) and comprehensive oral evaluation (D0150) provided on May 6, 2021.

You asked the Plan to pay for the scaling and comprehensive oral evaluation. You say that you now understand
that your insurance only covers one comprehensive oral evaluation every three years, but you do not
understand how you can change dentists within that three-year period. You also say that you changed dentists
due to the unsatisfactory treatment of your previous dental provider. The Plan denied your request. The Plan
says the scaling is not a covered benefit under your dental plan. The Plan also says that the comprehensive oral
evaluation exceeds the frequency limitation in your benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the scaling in presence of generalized
moderate or severe gingival inflammation (D4346) is not among those covered under this benefit. The contract
says that comprehensive oral evaluation (D0150) and is limited to one procedure every three plan years. The
record shows that you received a comprehensive oral evaluation (D0150) on September 26, 2019, and your
comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does
not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346)
and comprehensive oral evaluation (D0150) provided on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on May 7, 2021.

You asked the Plan to pay for the dental services. You say that the clerk at the dental office said they accepted your insurance. You say that you did what you were supposed to do, and you should be reimbursed. The Plan denied your request. The Plan says dental services received from an out-of-network 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on May 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an E2300 power seat elevation system.
You asked the Plan to pre-approve the requested repairs and E2300 power seat elevation system. You say that these repairs and accessories are medically necessary. The Plan denied your request. The Plan says while the repairs were approved, the E2300 power seat elevation system is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules specifically stated this accessory is not covered. Therefore, we decided that the Plan does not have to pre-approve power wheelchairs repairs and an E2300 power seat elevation system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Zoster vaccine and immunization administration provided on February 25, 2021.
You asked the Plan to reimburse you for the Zoster vaccine and immunization administration. You say that you want to be reimbursed for the vaccine. The Plan denied your request. The Plan says the vaccine is not covered under your Medicare Part B benefit
Medicare does not pay for or provide the Zoster vaccine and immunization administration. The Plan follows the same rules.
Therefore, we decided that the Plan does not have to reimburse you for the Zoster vaccine and immunization administration provided on February 25, 2021.
Benefits for the Zoster vaccine and immunization administration 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat facet injection.
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 repeat facet injections are 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 there is no documentation in the submitted records of the amount of pain relief you received from the previous facet joint injections. The criteria for coverage are not met; therefore, repeat injections are 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 a repeat facet injection.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan denied your request. The Plan says the benefit has been exhausted.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBT).
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 proton therapy is accepted as safe and effective for the treatment of lung cancer; however, it is not indicated over intensity modulated radiation therapy (IMRT) or stereotactic body radiation therapy (SBRT). There is no evidence that proton therapy is needed over other accepted treatments. There is no plausible reason that proton therapy would be more beneficial than standard therapy for this enrollee. The services are therefore 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 proton beam radiation therapy (PBT).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
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 device is unproven.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that imaging in 2019 has demonstrated multi-level disease moderate to severe spinal stenosis at L4-L5, the level requested for treatment. The record does not document that the enrollee is not indicated for surgery at no more than two levels. The elements of the coverage criteria are not satisfied. 
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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transthoracic echocardiography (93306) provided on
February 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the diagnostic services. You say that please have the claim reviewed and
reprocessed. The enrollee presented to the emergency department with complaints of shortness of breath. An
echo was medically indicated. 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. Nonemergent
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 transthoracic echocardiography (93306)
provided on February 11, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network chiropractic services.
You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says this provider is not in network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 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 out of network chiropractic services