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

We decided that the Plan does not have to pay for the office visit provided on September 15, 2020 by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating 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 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 office visit provided on September 15, 2020 by a non-participating provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing services.
You asked the Plan to pre-approve the skilled nursing services. You say that the enrollee requires the skilled nursing services to heal properly. The Plan denied your request. The Plan says you no longer require daily skilled services and continuation of the skilled nursing facility admission is not medically necessary.
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 the skilled nursing services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs or skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020) and trifocal lenses (V2303) provided on January 21, 2021.

You asked the Plan to pay for eyeglass frames and trifocal lenses. You say that you were told that the glasses would be paid for. You also say this is the first time you use your benefit. The Plan denied your request. The Plan says you exhausted your benefit, and you are responsible for the remaining balance.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when The Plan contract says that you have a $250 allowance once every calendar year to use towards the purchase of eyewear. 

We looked at the file and the Plan's rules. The records show you exhausted your $250 maximum allowed benefit on January 21, 2021. The records also show that you purchased eyeglass frames at $49 and trifocal lenses at $287.20, for a total cost of $336.20. You received the total allowed amount of $250, leaving a balance of $86.20 ($336.20 - $250 = $86.20). Based on this information, we decided that the Plan's rules for coverage of eyeglass frames and trifocal lenses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020) and trifocal lenses (V2303) provided on January 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the bladder catheterization procedure you had on April 27, 2021.
You asked the Plan to waive the copayment for the bladder catheterization procedure. You say that this was not surgery, so the surgery copayment should not have applied. The Plan denied your request. The Plan says it has adjusted your copayment so that you only owe $75. The Plan says that this copayment is correct.
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 $75 copayment for diagnostic procedures and tests. You have been asked to pay a $75 copayment for the bladder catheterization procedure. The bladder catheterization procedure falls within the diagnostic procedures and tests 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 bladder catheterization procedure you had on April 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure (destruction of the intraosseous
basivertebral nerve).
You asked the Plan to pre-approve the Intracept procedure. You say that there are several studies which support
that this treatment is safe and effective. It is felt that it would be the best choice for this patient. The Plan
denied your request. The Plan says there is not sufficient peer-reviewed literature to support this procedure.
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 Intracept procedure. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee has low back pain. The Intracept procedure is experimental for back
pain. 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 Intracept procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Intracept procedure (destruction of the intraosseous basivertebral nerve).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702).
You asked the Plan to pre-approve a MyoPro orthosis. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is experimental/investigational.
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 MyoPro orthosis. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested robotic orthosis is not proven to be more beneficial for treatment of the enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy, such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and/or Botox for spasticity if needed. The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that a MyoPro orthosis will improve the long-term outcomes for the enrollee, improve hemiparetic arm function, or be safe for long-term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. 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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on May 11, 2021.
You asked the Plan to pay for an eye refraction. You say that you visited the provider for a medical problem with your left eye along with a routine eye exam which resulted in needing glasses. The Plan denied your request. The Plan says an eye refraction is only covered by the Plan when performed as part of a routine screening.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that an eye refraction is only covered by the Plan when it is performed as part of a routine screening by a participating provider. We looked at the file and the Plan's rules. The eye refraction was performed as part of a medical vision exam, and therefore is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81120, 81235, 81272, 81121, 81201, 81275, 81173, 81235, 81276, 81210, 81270, 81301) provided on January 6, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for Guardant360 testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.
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 Guardant360 testing (81120, 81235, 81272, 81121, 81201, 81275, 81173, 81235, 81276, 81210, 81270, 81301) provided on January 6, 2021, by an out-of-network (OON) provider
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on December 15, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim should be submitted to Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee o December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on March 30, 2021.
You asked the Plan to pay for an eye refraction. You say that you called the Plan to find a participating provider. You also say you do not understand why the refraction is not covered. The Plan denied your request. The Plan says eye refractions are only covered by your plan if performed by a participating provider and the services are performed as a routine vision screening.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that an eye refraction is only covered by the Plan when it is performed as part of a routine screening by a participating provider. We looked at the file and the Plan's rules. The eye refraction was performed as part of a medical vision exam, and therefore is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on March 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care you received from February 1, 2021, to February 7, 2021.

You asked the Plan to waive the copayment for the inpatient hospital care. You say that you should not have to pay this copayment due to an incorrect diagnosis and poor quality of care you received in the hospital. 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 $385 copayment per day for days 1-5 for inpatient hospital care. 

You have been asked to pay a $385 copayment per day for days 1-5 for the inpatient hospital care. This copayment applies regardless of your satisfaction with the care you received. 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 inpatient hospital care you received from February 1, 2021, to February 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code E1399 that
were issued on July 14, 2020.
You asked the Plan to pay for the compression stockings. You say that you needed these items immediately,
having just completed lymphedema therapy and paid for them out of pocket. The claims were prepared by the
provider, but it appears the codes were incorrect and the descriptions unclear. The Plan denied your request.
The Plan says if you get services that are excluded, you must pay for them yourself.
The Plan must follow Medicare rules. Medicare rules also say that compression bandages and gradient
compression wraps are covered only when they are used as dressings over a qualifying wound.
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you
do not have a medical condition for which compression stockings can be covered or paid for by Medicare.
Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code
E1399 that were issued on July 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on March 24, 2021.

You asked the Plan to pay for the comprehensive periodontal evaluation. You say that the wrong dental code was originally appealed, and the correct code should be for a comprehensive periodontal evaluation (D0180). 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, periodontal exam (D0180) and comprehensive oral evaluation (D0150) share a frequency limitation of one procedure code every three calendar years. The record shows that you received a comprehensive periodontal evaluation (D0180) on May 7, 2021 and your periodontal exam (D0180) and comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0365) provided on May 12, 2021.
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that this x-ray was medically necessary because there was a mass that the provider could not identify completely to see if it was dental related without this imaging to confirm. The Plan denied your request. The Plan says this procedure is not covered by 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, 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 cone beam CT capture and interpretation (D0365) provided on May 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested admission is medically necessary. The Plan denied your request. The Plan says the requested services can be provided at a lower level of care.
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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment will be met in this case.
Our physician reviewer found the provided documentation indicates that you were not in respiratory distress, did not have ischemia, and there was no need for emergent hemodialysis. The reviewer found that there is no expectation that you would require hospital services that would likely cross 2 midnights. Therefore, the reviewer found that the requested inpatient care is 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 acute inpatient hospital care have not been met. Specifically, the file does not indicate that there is no expectation that you would require hospital services that would likely cross 2 midnights. Therefore, we decided that the Plan does not have to pre-approve the requested acute inpatient hospital care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on February 22, 2021 by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating 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 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 physical therapy services provided on February 22, 2021 by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on November 3, 2020.
You asked the Plan to pay for the cardiovascular risk assessment 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. Cardiovascular risk assessment panels are only covered for certain indications. Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129, L36262, and L36523 to support their denial. However, LCD L36139, L36129, L36262, and L36523 are not valid for the provider's billing state of Pennsylvania. Therefore, we are unable to use LCD L36139, L36129, L36262, and L36523 to substantiate our decision. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on November 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided May 14, 2021.
You asked the Plan to pay for the limited oral exam. You say that the exam was necessary. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service and therefore it is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the limited oral exam twice per calendar year. We looked at the file, and Medicare rules. The Plan previously covered oral exams on January 13, 2021, and April 15, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided May 14, 2021.