Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation and cone beam CT capture provided on May 10, 2021.

You asked the Plan to pay for the limited oral evaluation and cone beam CT capture. You say that you weren't aware that the dentist office didn't accept your plan. The Plan denied your request. The Plan says the provider does not participate with your 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, 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 limited oral evaluation and cone beam CT capture provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the five additional intraoral periapical x-rays (D0230 x5) provided on May 6, 2021.
You asked the Plan to pay for the additional intraoral periapical x-rays. You say that you do not have the finances to allow you to afford paying copays. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation 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, intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) on May 6, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the five additional intraoral periapical x-rays (D0230 x5) provided on May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 10, 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 multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. 

We looked at the file and Medicare rules. The records in this case show that more than 5 pathogens were targeted in this panel. 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 provided on April 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided on March 5, 2021.
You asked the Plan to waive the copayment for an x-ray. You say that you do not feel like you should have to pay for this because the first surgery was not successful. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $35 copayment for outpatient diagnostic tests/in-network/x-rays/specialist. 
You have been asked to pay a $35 copayment for an x-ray. an x-ray falls within the outpatient diagnostic tests/in-network/x-rays/specialist 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 an x-ray provided on March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator (E1399, A9901).
You asked the Plan to pay for the portable oxygen concentrator. You say that you would like this claim
reprocessed with your cost sharing. The Plan denied your request. The Plan says purchased oxygen is not
eligible for payment.
The Plan must follow Medicare rules. Medicare rules say that no payment will be made for oxygen equipment
that is purchased.
We looked at the file and Medicare rules. In this case, the record indicates that the equipment was purchased
and not rented as required by 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 pay for the portable oxygen concentrator (E1399, A9901).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the full cardiology genetic panel provided on January 21, 2021.

You asked the Plan to pay for the full cardiology genetic panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The full cardiology genetic panel at issue in this appeal 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 full cardiology genetic panel provided on January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation trips (A0100).

You asked the Plan to pre-approve additional transportation trips. You say that you need additional transportation trips for medical appointments. The Plan denied your request. The Plan says you have utilized the maximum number of transportation trips allowed per year.

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 20 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 transportation trips (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lift chair provided on September 17, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for a lift chair. You say that this was the least expensive option. You say that the in-network providers were too expensive. The Plan denied your request. The Plan says there are in-network providers available to provide these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a lift chair provided on September 17, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening panel provided on March 21, 2021.
You asked the Plan to pay for the panel testing. The Plan denied your request. The Plan says the clinical value has not been demonstrated.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. We looked at the file and the rules. In this case, there are insufficient medical records to show the results of the testing would be used to determine a specific diagnosis or treatment strategy. The panel testing was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening panel provided on March 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas machine along with subcutaneous vitamin injections provided from January 26, 2021 to February 9, 2021.
You asked the Plan to pay for the Sanexas machine along with subcutaneous vitamin injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered 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 pay for the Sanexas machine along with subcutaneous vitamin injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has neck, back, leg pain for more than 10 years with idiopathic progressive polyneuropathy. There was no evidence of the enrollee having tried these treatments leading to long-term functional benefit to justify the repeat use. Also, there was no evidence of vitamin deficiency to justify the vitamin injections. Therefore, without sufficient support made for this request, the Sanexas machine use along with subcutaneous vitamin injections will be considered not medically necessary. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Sanexas machine along with subcutaneous vitamin injections have not been met. Therefore, we decided that the Plan does not have to pay for the Sanexas machine along with subcutaneous vitamin injections provided from January 26, 2021 to February 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate.
You asked the Plan to pre-approve bone marrow aspirate. 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 bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental for use as bone graft material. 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sixteen (16) additional PT visits.

You asked the Plan to pre-approve sixteen (16) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.

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 sixteen (16) additional PT visits. 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 that based on review of the available records, you do not meet Medicare coverage criteria for the services provided by a nurse practitioner (NP) in the form of PT. You were evaluated and treated by an FNP. The treatments described above for diabetic neuropathy were provided by an NP and this is not standard PT practice. The documentation of services does not support physical therapy treatments or prescription for coverage for the therapy visits. The requested therapy is not generally accepted as specific and effective therapy for your condition. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sixteen (16) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve sixteen (16) additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-ray (D0274), the initial periapical x-ray
(D0220), and the additional periapical x-ray (D0230) provided on April 27, 2021.

You asked the Plan to pay for the dental services. You say that dental x-rays have always been part of the
regular checkup. You say that you are surprised at the denial to pay for routine dental services. The Plan denied
your request. The Plan says x-rays are not listed as covered 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 bitewing x-rays and periapical xrays
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay
for the bitewing x-ray (D0274), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230)
provided on April 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on April 15,
2021 by an OON provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that the treatment provided to the
enrollee was medically necessary. The Plan denied your request. The Plan says prior authorization was not
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 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 subsequent nursing facility care provided on
April 15, 2021 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Minuteman device (22612 and 22840).

You asked the Plan to pre-approve a Minuteman device. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Minuteman device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the minuteman device is experimental in spinal surgery and more research is needed to show safety and efficacy of the device. 

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 Minuteman device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Minuteman device (22612 and 22840).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin injections provided on January 21, 2021.
You asked the Plan to pay for the vitamin injections. You say that the claim should be reviewed and
reprocessed for correct payment. The Plan denied your request. The Plan says with the available information,
this is not a Medicare covered benefit.
The Plan must follow Medicare rules. Medicare rules say that claims for compounded drugs shall be submitted
using a compounded drug, not otherwise classified (NOC) code.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the vitamin injections have not been met. Specifically, the multiple drug codes reported on this
claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be
billed using the not otherwise classified code J7999. As this compounded drug was not billed properly,
payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also
cannot be paid. Therefore, we decided that the Plan does not have to pay for the vitamin injections provided on
January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on March 3, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. You say that these services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided on March 3, 2020 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an osteogenesis stimulator for the enrollee.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied
your request. The Plan says there has not been two sets of x-rays 90 days apart that show no healing of the
bone.
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs
separated by a minimum of 90 days.
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 stimulator. Our reviewer says that
the requested stimulator is not medically reasonable or necessary. Our physician reviewer found that in this
case, the record indicates that the enrollee suffered a fractured fifth metatarsal bone in August 2021. The record
contains one set of x-rays. 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 stimulator have not been met. Therefore, we decided that the Plan does not
have to pre-approve an osteogenesis stimulator for the enrollee
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 that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.

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 that the enrollee appears to be more stable but requires additional short-term acute care hospital services to further treat and monitor, which can be safely completed at the current facility. Chest tube management is still required, making the enrollee not yet stable for transfer. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this transfer is not clinically advantageous. Transfer may be considered when the enrollee is more stable and when treatment has completed.

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.