Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of a positive airway pressure (CPAP)
device and supplies.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the data does not show compliance.
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 services.
Our reviewer says that the requested services are not considered medically reasonable and necessary in this
case. Our physician reviewer found you have not been able to use the device sufficiently to be effective. The
compliance report from November 2021 shows use for at least four hours a day 37% of days. This does not
meet the minimum Medicare criteria of at least 70% days. The medical records do not indicate the compliance
issue has been addressed.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continuation of a positive airway pressure (CPAP) device and supplies.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services (97110) and
outpatient hospital surgical services (29581) provided from June 16, 2021, to June 28, 2021.

You asked the Plan to waive the copayment the physical therapy services and outpatient hospital surgical
services. You say that the services should be covered as you were sent to different facilities and were only there
for a short time. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the
services provided

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 $40
copayment for Outpatient Rehabilitation Services and a $275 copayment for Hospital Outpatient Facilities and
Ambulatory Surgical Centers.

You have been asked to pay a $120 copayment for physical therapy services and a $628.2 copayment for 3
separate visits of outpatient hospital surgical services, which is less than the $275 per day stated in the Plan's
contract. the physical therapy services and outpatient hospital surgical services falls within the Outpatient
Rehabilitation Services and Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 physical therapy services (97110) and outpatient hospital
surgical services (29581) provided from June 16, 2021, to June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the root canal (D3310) provided on September 14, 2021.
You asked the Plan to waive the coinsurance for the root canal. You say that the provider put you in a dangerous situation, where you ended up in the hospital, and you believe you should not be held responsible for this charge. The Plan denied your request. The Plan says this claim processed correctly according to your 2021 Evidence of Coverage.
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 Plan offers a maximum $2,500 allowance with a 50% coinsurance every year for supplemental comprehensive dental services, including root canals. The record shows that the approved allowed cost for this service is $295, which means the coinsurance of 50% is $147.50. Therefore, we decided that the Plan does not have to waive the coinsurance for the root canal (D3310) provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on August 13, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not
covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for the chiropractic services provided on August 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be unstable due to likely aspiration pneumonia and should only require short-term additional acute care services that can be safely completed at the current facility until more stable. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more stable.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammogram you received on July 20, 2021.
You asked the Plan to pay for the mammogram. The Plan denied your request. The Plan says the benefit limit
has been exceeded.
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 $0
copayment for one screening mammogram every 12 months.
Review of the file shows that you were provided a screening mammogram on July 20, 2021. The records also
show that you had a covered mammogram on September 9, 2020. As the requested mammogram was provided
less than 12 months after the covered service, the benefit limit has been exceeded.
This means that you have been asked to pay the correct amount based on your contract with the Plan.
Therefore, we decided that the Plan does not have to pay for the mammogram you received on July 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from July 7, 2020, to July 21, 2020.

You asked the Plan to pay for home health services. You say that this was originally filed timely. The Plan denied your request. The Plan says this was filed more than a year after the service.

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 home health services was not filed until July 27, 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 home health services provided from July 7, 2020, to July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite of one surface (D2391) and resin-based composite of three surfaces (D2393) provided on August 9, 2021, and August 19, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the resin-based composites. You say that your plan states that you have a $2,000 benefit and you would like these services to be paid accordingly. The Plan denied your request. The Plan says these services were performed by a non-participating provider. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for 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, you are responsible for a 55% coinsurance of the allowed amount for restorations, plus the difference between the billed amount and allowed amount because these services were received OON. Therefore, we decided that the Plan does not have to pay for the resin-based composite of one surface (D2391) and resin-based composite of three surfaces (D2393) provided on August 9, 2021, and August 19, 2021 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 psychiatric services provided on May 23, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not
payable for these services.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Marriage family therapists are not eligible to enroll in the Medicare program. Therefore, we decided
that the Plan does not have to pay for the psychiatric services provided on May 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on April 23, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was not ordered by the treating physician.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. We looked at the file and Medicare rules. In this case, the records do not show that the testing in question was ordered by the enrollee's treating physician. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on April 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar interspinous decompression device (CPT code
22899) for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the requested lumbar interspinous decompression device is unproven and not medically
necessary due to insufficient evidence of efficacy.
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 services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found interspinous process distraction devices remain experimental. More research is needed to show
safety and efficacy.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve lumbar interspinous decompression device (CPT code 22899) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (88361) provided on March 4, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the lab services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 60-year-old female with Barrett's esophagus without dysplasia. WATS 3D testing was performed. Based on current evidence on this testing method, it does not have sufficient supportive high-quality studies to expect a significantly better overall outcome compared to standard testing methods. Therefore, this request is considered not medically necessary at this time. 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 lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services (88361) provided on March 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998),
provided on May 5, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you fell and that
the paramedics helped you get up. You say that after calming down, you decided to not go to the emergency
room. The Plan denied your request. The Plan says per Medicare guidelines, the Medicare ambulance benefit is
a transportation benefit and without a transport there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on May 5, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport
(A0998), provided on May 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 13, 2021, through July 15, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says the inpatient admission was not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 13, 2021, through
July 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on
December 31, 2020, through January 1, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the service should be
covered. The Plan denied your request. The Plan says the cost share 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 $100
copayment per day one through five for inpatient hospital care.
You have been asked to pay a $100 copayment per day one through five for the inpatient hospital care. This
service falls within the inpatient hospital 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 waive the copayment
for the inpatient hospital care provided on December 31, 2020, through January 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus vaccine you received on September 17, 2021.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not a covered
benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The
Plan follows the same rules.
The records do not show that you have been injured or directly exposed to any illness related to the vaccine.
Therefore, we decided that the Plan does not have to pay for the tetanus vaccine you received on September 17,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified adjunctive procedure (D9999) provided on January 16, 2020.

You asked the Plan to pay for the adjunctive procedure. You say that you are aware of the Plan's 365-day rule, but the Plan received your original filings timely, and you were not advised until later that they were not in proper format. The Plan denied your request. The Plan says you received non-Medicare-covered dental services on January 16, 2020. The Plan also says that your request for reimbursement of this service was received on July 21, 2021, which is after the 365-day timely filing limit for dental reimbursements.

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 adjunctive procedure was not filed until July 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 unspecified adjunctive procedure (D9999) provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) provided on September 13, 2021, by
an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that your physician is a contracted provider in network
and the referrals for the office visits are not required. The Plan denied your request. The Plan says this service
was not authorized, and the Plan has confirmed that this was not an ambulance service, emergency and urgently
needed, post stabilization care, nor dialysis while outside the service area. The Plan also says that they
completed a thorough review and determined that both the referring and attending providers are all non-
participating with the Plan.
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 an office visit (99203) provided on September 13,
2021, 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 exercise equipment purchased on April 14, 2021.

You asked the Plan to pay for the exercise equipment. You say that the items should be covered. The Plan denied your request. The Plan says exercise equipment is not covered as durable medical equipment and is not covered under your plan's Wellness Allowance.

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. The Plan's Wellness Allowance only covered gym memberships and not purchased exercise equipment. Therefore, we decided that the Plan does not have to pay for the exercise equipment purchased on April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), and prophylaxis (D1110), provided on September 9, 2021.
You asked the Plan to pay for the oral exam and prophylaxis. You say that the service should be covered. The Plan denied your request. The Plan says the services were received out-of-network.
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 periodic oral evaluation (D0120), and prophylaxis (D1110), provided on September 9, 2021.