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

 We decided that the Plan does not have to pay for physical therapy services provided from April 30, 2021, through August 5, 2021.  You asked the Plan to pay for physical therapy services. You say that you have been to a few different doctors for your back pain, and they all say it is something different but to try going to a chiropractor to help. You say your back pain level would be described at a level 12 and the chiropractor has helped. You say that you were not aware the physical therapy was not covered with the spinal manipulation. The Plan denied your request. The Plan says that the Plan covers only manual manipulation of the spine to correct subluxation. Routine coverage only covers manual manipulation of the spine to correct subluxation.  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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for physical therapy services provided from April 30, 2021, through August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an intraoral periapical first radiographic image (D0220) and an intraoral periapical additional radiographic image (D0230) provided on July 30, 2021.  You asked the Plan to pay for an intraoral periapical first radiographic image and an intraoral periapical additional radiographic image. You say that you were told by the provider's office that the services should be covered. You also say you are requesting payment to be sent directly to the provider's office as soon as possible. The Plan denied your request. The Plan says the services at issue are not covered under your Plan under any circumstances.  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 an intraoral periapical first radiographic image (D0220) and an intraoral periapical additional radiographic image (D0230) provided on July 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient hospital visit services provided on  June 16, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the outpatient hospital visit services. You say that the services were 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 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 record shows CPT code 36415 was billed which means the provider had the opportunity to confirm insurance coverage and authorization. Therefore, we decided that the Plan does not have to pay for the outpatient hospital visit services provided on June 16, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for Purewick external catheter supplies provided from  February 23, 2021, to June 3, 2021.  You asked the Plan to pay for external catheter supplies. You say that these supplies were medically necessary. The Plan denied your request. The Plan says the denial of payment for these supplies is correct, because this provider does not accept Medicare and is not payable.  The Plan must follow Medicare rules. Medicare rules say that in order to receive payment for covered items, a supplier must be enrolled in the Medicare program.   We looked at the file and Medicare rules. This supplier is not enrolled in Medicare and is not payable. Based on this information, we decided that Medicare rules for coverage of external catheter supplies have not been met. Therefore, we decided that the Plan does not have to pay for Purewick external catheter supplies provided from February 23, 2021, to June 3, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the debridement provided on July 21, 2021.  You asked the Plan to pay for the debridement. You say that the service was performed in good faith. The Plan denied your request. The Plan says that no prior authorization was obtained.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit the Evidence of Coverage. This means we cannot determine if the Plan's denial of non-emergent services is supported Therefore, we decided that the Plan has to pay for the debridement provided on July 21, 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the urinary tract infection (UTI) and sexually transmitted infection (STI) by nucleic acid provided on June 8, 2021.  You asked the Plan to pay for the genetic UTI/STI testing. You say that this was medically necessary testing. The Plan denied your request. The Plan says this is not a clinically proven test.  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 genetic UTI/STI testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a male with a history of insomnia, myalgia, and left femur fracture with repair. There is no documentation provided indicating why a standard urine culture was not performed. The clinical value of urine/STI nucleic acid panel testing in the setting of urinary tract infection remains unproven in the peer-reviewed literature. The review has determined that the items/services at issue in this case are not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic UTI/STI testing have not been met. Therefore, we decided that the Plan does not have to pay for the urinary tract infection (UTI) and sexually transmitted infection (STI) by nucleic acid provided on June 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD) procedure and the colonoscopy you had at an outpatient hospital facility on July 15, 2021.  You asked the Plan to waive the copayment for the EGD and colonoscopy. You say that you were not given a choice as to whether or not you should have the EGD, so you don't think you should have to pay this copayment. 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 $350 copayment for outpatient surgery and services at an outpatient hospital facility.   You have been asked to pay a $350 copayment for the EGD and colonoscopy. The EGD and colonoscopy fall within the outpatient surgery and services at an outpatient hospital facility benefit category.  This copayment applies regardless of the reason for the procedure. 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 esophagogastroduodenoscopy (EGD) procedure and the colonoscopy you had at an outpatient hospital facility on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99335) rendered by the out-of-network (OON) provider on June 10, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99335) rendered by the out-of-network (OON) provider on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of previous root canal therapy provided on June 23, 2021.

You asked the Plan to pay for the retreatment of previous root canal therapy. You say that you used this provider in the past and did not have issues. You say that you would have gone somewhere else if you knew they were completely opted out. The Plan denied your request. The Plan says we are unable to make payments for services provided by a dentist who has opted out of Medicare.

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, retreatment of previous treatments are not among those covered under this benefit. Please note, we could not confirm the provider has opted out of Medicare, but the service remains denied as a non-covered benefit. Therefore, we decided that the Plan does not have to pay for the retreatment of previous root canal therapy provided on June 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time required due to a public health emergency for services provided from January 18, 2021, through January 22, 2021, billed with code 99072.  You asked the Plan to pay for the services as billed. You say that this is an approved code and should be paid due to additional resources required due to the pandemic. The Plan denied your request. The Plan says this is not a payable code.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  Code 99072 has a status indicator of B on the Physician Fee Schedule. This means that payment for this service is bundled with payment made for other services. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time required due to a public health emergency for services provided from January 18, 2021, through January 22, 2021, billed with code 99072.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the pacemaker surgery you had on  June 7, 2021, at an outpatient hospital facility.  You asked the Plan to waive the copayment for the pacemaker surgery. You say that this procedure had to be done at the hospital, so you don't think you should be charged for this. 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 $275 copayment for outpatient surgery at an outpatient hospital facility.    You have been asked to pay a $275 copayment for the pacemaker surgery. The pacemaker surgery falls within the outpatient surgery at an outpatient hospital facility benefit category. This copayment applies regardless of the necessity of the procedure. 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 pacemaker surgery you had on June 7, 2021, at an outpatient hospital facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a tetanus, diphtheria toxoids, and acellular pertussis (TDAP) immunization provided on June 29, 2021.  You asked the Plan to pay for TDAP immunization. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this immunization is not covered by Medicare Part B benefits.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide TDAP immunization. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to TDAP immunization. Therefore, we decided that the Plan does not have to pay for a tetanus, diphtheria toxoids, and acellular pertussis (TDAP) immunization provided on June 29, 2021.   Benefits for TDAP immunization 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a replacement power wheelchair.  You asked the Plan to pre-approve a replacement power wheelchair. You say that not having a power wheelchair makes you homebound and is unsafe for you. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.  The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the reasonable useful lifetime of equipment in no case can be less than 5 years. Computation of the useful lifetime is based on when the equipment is delivered to the enrollee, not the age of the equipment.  We looked at the file and Medicare rules. In this case, you are requesting a replacement for a power wheelchair received in December 2020. Therefore, the requested replacement is for an item that has not outlasted its reasonable useful lifetime. Based on this information, we decided that Medicare rules for coverage of a replacement power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided from April 22, 2021, through April 23, 2021.  You asked the Plan to pay for the self-administered drugs. You say that the self-given drugs were part of the ablation and you are not sure why they were denied. The Plan denied your request. The Plan says the medications do not qualify for reimbursement under your Part A & B benefits.   The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from April 22, 2021, through April 23, 2021.   Benefits for the self-administered drugs 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member has stabilized medically and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care.  Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The member does not have any parental medication; complex wound care or nutrition given via a feeding tube.  She is medically stable without any acute exacerbations of chronic medical problems.  Her physical function is at or near her baseline and she can receive services at a lower level of care.  Admission to a SNF for inpatient skilled rehab services is 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Aduhelm for the enrollee.  You asked the Plan to pre-approve the drug. You say that  The Plan denied your request. The Plan says this drug is considered experimental and investigational.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the documentation does not support that Aduhelm is medically reasonable and necessary for the enrollee in this case. The documentation is insufficient to support a diagnosis of Alzheimer's disease in this case. The case file does not contain objective assessment of cognitive function. Apo E is associated with normal lipid metabolism. The documentation does not support that Aduhelm is safe and effective for this enrollee. It has not been demonstrated that Aduhelm is at least as beneficial as existing and appropriate and available medically appropriate alternatives for this enrollee.  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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the primary care visit you had on July 22, 2021.  You asked the Plan to waive the copayment for the primary care visit. You say that this was an annual wellness exam that should be free once a year with no copayment. 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 $10 copayment for primary care office visits.   You have been asked to pay a $10 copayment for the primary care visit. The billing records show that although you did have an annual wellness visit on this date (code G0439) for which no copayment applied, you also had a separate and distinct evaluation by your doctor to evaluate you for thypertension and atherosclerotic heart disease.  These are services beyond the scope of an annual wellness visit, so an office visit copayment applies. 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 primary care visit you had on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the resin-based composite - four or more surfaces, posterior (D2394), resin-based composite - three surfaces, posterior (D2393), resin-based composite - two surfaces, posterior (D2392), and inhalation of nitrous oxide/analgesia, anxiolysis (D9230) provided June 16, 2021.  You asked the Plan to pay for the fillings and nitrous oxide/analgesia. You say that the provider or Plan should be responsible for understanding your benefits and communicating them to you. The Plan denied your request. The Plan says you have exceeded the frequency limit for fillings and the nitrous oxide isn't covered unless provide with a covered 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. The Plan covers the fillings twice per plan year. The Plan covers anesthesia along with covered services.   We looked at the file and Medicare rules. The Plan provided documentation showing that two fillings were covered on May 24, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the fillings has been exceeded. Since the fillings are not a covered service in this case, the nitrous oxide also is not covered. Therefore, we decided that the Plan does not have to pay for the resin-based composite - four or more surfaces, posterior (D2394), resin-based composite - three surfaces, posterior (D2393), resin-based composite - two surfaces, posterior (D2392), and inhalation of nitrous oxide/analgesia, anxiolysis (D9230) provided June 16, 2021.