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

We decided that the Plan does not have to pre-approve the MyopPro2, Motion G orthotic device (L8702).

You asked the Plan to pre-approve the orthotic device. You say that given traditional therapies have been tried and failed, the enrollee has been referred for myoelectric orthotic restoration. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke lack of clinical evidence demonstrating an impact on improved health outcomes.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyopPro2, Motion G orthotic device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit with a dermatologist on January 8, 2021.

You asked the Plan to waive the copayment for the dermatology telehealth visit. You say that you actually called into the Plan with a question about a hospital bed, but you are also appealing this copayment. The Plan denied your request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $15 copayment for telehealth visits with a specialist. 

The enrollee has been asked to pay a $15 copayment for the dermatology telehealth visit.

The dermatology telehealth visit falls within the telehealth visits with a specialist benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the telehealth visit with a dermatologist on January 8, 2021. Please note that if you have questions regarding a denial for a hospital bed, you will need to contact the Plan directly regarding that issue.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urinalysis provided on January 8, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the urinalysis. You say that you would like the service paid as in-network. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the urinalysis provided on January 8, 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 oncology office visit provided on March 31, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the oncology office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the oncology office visit provided on March 31, 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 out of network physician services provided to the enrollee on March 31, 2021.

You asked the Plan to pay for out of network physician services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 out of network physician services provided to the enrollee on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided on November 23, 2020.
You asked the Plan to pay for anesthesia for procedures on major vessels of neck (00350). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the 151 units is inconsistent with the 148 units represented in the medical records.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that 151 units of CPT code 00350 are not supported in the medical record. The medical record only supports 148 units of CPT code 00350. Based on this information, we decided that Medicare rules for coverage of anesthesia for procedures on major vessels of neck (00350) have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services provided on November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hyperbaric oxygen therapy (99183) provided January 3, 2020, to January 31, 2020.

You asked the Plan to pay for the hyperbaric oxygen therapy. You say that you would like this corrected claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was filed past 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 hyperbaric oxygen therapy was not filed until April 22, 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 hyperbaric oxygen therapy (99183) provided January 3, 2020, to January 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2393) provided on May 5, 2021.

You asked the Plan to pay for the resin-based composite. You say that you were not aware that this service was not covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 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 resin-based composite (D2393) provided on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar radiofrequency ablation (RFA).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that RFA is covered when specific criteria are met. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has back pain secondary to spondylosis. She has not had two diagnostic injections of the L2 to L4 spine with significant pain relief. The documentation does not support that she had a minimum of 50 percent improvement in pain or functional abilities for at least six months to warrant repeat RFA. 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 lumbar radiofrequency ablation (RFA).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on December 30, 2019.
You asked the Plan to pay for ambulance service, advanced life support, emergency transport, level 1. The Plan denied your request. The Plan says the claim was received beyond the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for ambulance service, advanced life support, emergency transport, level 1 was not filed until March 11, 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 ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on December 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation facility (IRF) services you received from May 14, 2021, to May 27, 2021.

You asked the Plan to waive the copayment for the IRF services. You say that you were charged for a hospital service when you believe you were in a skilled nursing facility. The Plan denied your request. The Plan says you were charged this copayment 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 $260 copayment for days 1-4 for inpatient hospital services, including inpatient rehabilitation. 

You have been asked to pay a $260 copayment for days 1-4 for the IRF services. Records show that the facility where you received care is considered an inpatient rehabilitation facility, not a skilled nursing facility. Your Evidence of Coverage clearly states that the inpatient hospital copayment applies to inpatient rehabilitation services. 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 rehabilitation facility (IRF) services you received from May 14, 2021, to May 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee orthosis (L1852).

You asked the Plan to pre-approve the orthosis. You say that unloader braces are very helpful for pain relief and may help the enrollee avoid a costly and difficult surgery. Please reconsider approval for his braces. The Plan denied your request. The Plan says the requested knee brace is not medically necessary because the records do not show that you had a recent injury or surgery to your knee or that your knee is unstable.

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 orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee has arthritis in the knees. There is no documentation of a recent injury or surgery to the knee and the notes do not show that the knee is unstable on exam. The medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 

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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the knee orthosis (L1852).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic care provided on May 3, 2021 to May 13, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the chiropractic care. You say that you were not told the provider was not a participating provider. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 chiropractic care provided on May 3, 2021 to May 13, 2021 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on March 1, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that you cannot afford this copayment and you said the customer service agent provided you with a list of hospitals instead of urgent care centers. The Plan denied your request. The Plan says you were charged this copayment 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 $120 copayment for emergency room visits. 

You have been asked to pay a $120 copayment for the ER visit. This copayment applies regardless of the reason for the ER visit. 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 emergency room (ER) visit you had on March 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiomyopathy rick factor screening (81286, 81407, 81408, 81479) provided on September 10, 2020.

You asked the Plan to pay for cardiomyopathy rick factor screening. You say that this was medically necessary. The Plan denied your request. The Plan says this is not supported.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. 

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of cardiomyopathy rick factor screening have not been met. Therefore, we decided that the Plan does not have to pay for cardiomyopathy rick factor screening (81286, 81407, 81408, 81479) provided on September 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Coflex device surgery for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that the requested Coflex 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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The coflex device
remains experimental. High failure rates have been reported with similar devices in spinal surgery. Our
physician reviewer found that the enrollee's condition does not meet Medicare criteria for 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 Coflex device surgery for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 29, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you had to go to a new dentist office because your previous dentist office had closed, which is not your fault. The Plan denied your request. The Plan says your benefit maximum has been met for this service.
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, comprehensive oral evaluation (D0150) is limited to one every 36 months. The record shows that you received a comprehensive oral evaluation (D0150) on October 29, 2019 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from April 3, 2021, to April 19,
2021, by an OON provider.
You asked the Plan to pay for the dental services. You say that you needed to see a dentist immediately and
believe these services should be covered. The Plan denied your request. The Plan says these services were
rendered by a non-participating provider. The Plan also says that services need to be provided in-network to be
eligible for payment.
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
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the dental
services provided from April 3, 2021, to April 19, 2021, by an OON provider.
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. The Plan denied your request. The Plan says your medical needs are being met in the current acute setting.

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 physician reviewer found that in this case, you were admitted to the acute care hospital with a draining wound due to esophageal fistula following cervical fusion. You have had a prolonged hospital course including aspiration pneumonia and nutritional deficits. You are improving. You continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy provided on March 18, 2021.

You asked the Plan to waive the coinsurance for chemotherapy. You say that you have never had to pay these charges in the past. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for chemotherapy services for outpatient hospital services. 

You have been asked to pay $3,335.00, which is less than the 20% coinsurance for chemotherapy. Chemotherapy falls within the outpatient hospital services 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 coinsurance for chemotherapy provided on March 18, 2021.