Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.  You asked the Plan to pre-approve the Vertiflex procedure. You say that the Vertiflex procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this is considered experimental/investigational at this time.  
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 Vertiflex procedure. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on May 28,
2021
You asked the Plan to pay for the periodontal maintenance. You say that this procedure is very similar to the
services you received on September 14, 2021, and the amount of those services is greater than that of the
periodontal maintenance. You also say that both processes took about the same time, ultrasound cleaning was
used, and no operation was performed below the gum line. The Plan denied your request. The Plan says this
procedure is not a 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
periodontal maintenance (D4910) provided on May 28, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the ultrasound (93880), outpatient visit
(99204), and routine electrocardiogram (EKG) (93000), provided on May 25, 2021, through June 3, 2021.
You asked the Plan to waive the cost share for the ultrasound, outpatient visit, and routine EKG. You say that
you shouldn't have to pay for these services. The Plan denied your request. The Plan says the cost share was
applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150
copayment for radiological diagnostic services for Outpatient Diagnostic Tests and Therapeutic Services and
Supplies.
You have been asked to pay a $150 copayment for radiological diagnostic services for the ultrasound, a $35
copayment for the outpatient visit, and $13.83 out of the $20 copayment for the routine EKG. These services
fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category and the
Physician/Practitioner Services, Including Doctor's Office Visits 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 cost share for the ultrasound (93880), outpatient visit (99204), and routine electrocardiogram
(EKG) (93000), provided on May 25, 2021, through June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on March 1, 2021, by an
OON provider.
You asked the Plan to pay for the anesthesia services. You say that you thought you would be covered seeing
an out-of-network 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 anesthesia services provided on March 1,
2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removal of torus palatinus (D7472) and an alveolus closed reduction (D7670).  
You asked the Plan to pre-approve a removal of torus palatinus and an alveolus closed reduction. You say that the two denied procedures are required for further dental work to be done. 
The Plan denied your request. The Plan says the requested dental services are not listed in the EOC and are not covered dental benefits under the 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 pre-approve a removal of torus palatinus (D7472) and an alveolus closed reduction (D7670).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a perfect sleep chair.  You asked the Plan to pre-approve the chair. You say that the chair best meets your needs and should be covered. The Plan denied your request. The Plan says this chair is not primarily medical in nature and is non-covered.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a perfect sleep chair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care,
provided on May 1, 2021, through June 1, 2021.
You asked the Plan to waive the copayment for the SNF care. You say that the service should be covered. The
Plan denied your request. The Plan says the cost share was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $0 per
day one through twenty and $184 per day twenty-one through sixty-two for skilled nursing facility (SNF) care.
You have been asked to pay $4,629.33 for the SNF care. You were in the SNF for a total of 52 days and 31 of
those days had a $184 copayment ($184 x 31 = $5,704). You reached your maximum out-of-pocket amount,
and therefore, were only asked to pay the $4,629.33. This service falls within the skilled nursing facility (SNF)
care benefit category. This means that you have been asked to pay the correct amount based on your contract
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF)
care, provided on May 1, 2021, through June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty (D4211) provided on
August 17, 2021.
You asked the Plan to pay for the gingivectomy or gingivoplasty. You say that this was a required operation to
repair the tooth and allow it to be fitted correctly. You also say that you would like this claim to be
reconsidered for coverage. 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
gingivectomy or gingivoplasty (D4211) provided on August 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76705) provided on August 25, 2021.  You asked the Plan to pay for an ultrasound. 
You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 is a column II code to column I code 93976. 
This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76705) provided on August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553),
provided on October 26, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the CGM supplies. You say that the item was medically necessary. The Plan
denied your request. The Plan says prior authorization must be obtained for non-emergent services obtained
through an out-of-network provider.

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 continuous glucose monitor (CGM) supplies
(K0553), provided on October 26, 2020 by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) and accessory (E0673).  You asked the Plan to pay for a pneumatic compression device. You say that you would like these items reprocessed for payment based on billing rules. The Plan denied your request. 
The Plan says this device is not covered by Medicare.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) and accessory (E0673).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on
June 16, 2020.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate if services are not available from preferred providers in the
service area. You say that the in-network benefits should be honored, and the claim processed for payment. The
Plan denied your request. The Plan says the code is not appropriate for the service billed.
The Plan must follow Medicare rules. Medicare rules say that services of a physical/occupational therapist
billed as services incident to a physician/non-physician practitioner's service must meet all incident
requirements.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse
practitioner. As such, physical therapy services cannot be paid incident to this provider's professional services.
Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical
therapist on June 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) of the lumbar spine.  
You asked the Plan to pre-approve CT of the lumbar spine. The Plan denied your request. The Plan says there is no clinical documentation to support a need for the requested CT scan.  
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. Medicare rules also say that information must be submitted to confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. 
The case file shows that the Plan made reasonable attempts to obtain medical records. However, no medical records were supplied. Without medical records, we are unable to confirm that Medicare coverage criteria have been met. 
Based on this information, we decided that Medicare rules for coverage of CT of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) of the lumbar spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor.  You asked the Plan to pre-approve the monitor. You say that the enrollee is currently taking a blood sugar medication to lower it in hopes of not being put on insulin. The Plan denied your request. The Plan says the enrollee is not on insulin.  
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.   We looked at the file and Medicare rules. 
The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit with ear wax removal you had with a physician's assistant in a otolaryngology office on August 16, 2021.  You asked the Plan to waive the copayment for the otolaryngology office visit. You say that the receptionist told you that you only had a $10 copayment because the provider is a physician's assistant. You also said that you believe you are being charged for visits you did not have. 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 $35 copayment for physician/practitioner services in a specialist's office.   You have been asked to pay a $35 copayment for the otolaryngology office visit. We looked at the medical records and confirmed that you did receive office visit services on August 16, 2021. The specialist copayment applies to both physician and non-physician practitioner services provided in a specialist's office. 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 office visit with ear wax removal you had with a physician's assistant in a otolaryngology office on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ophthalmology services provided on May 3, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the services provided. You say that the enrollee was seen for diabetic care for his vision. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.  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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the ophthalmology services provided on May 3, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy (PT) evaluation
(97161), provided on June 21, 2021.
You asked the Plan to waive the copayment for the PT evaluation. You say that the service should be covered.
The Plan denied your request. The Plan says the cost share was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25
copayment for outpatient rehabilitation services.
You have been asked to pay a $25 copayment for the PT evaluation. This service falls within the outpatient
rehabilitation 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 copayment for the physical
therapy (PT) evaluation (97161), provided on June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (A9276, A9277, A9278).  
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is a non-therapeutic monitor.  
The Plan must follow Medicare rules. The rules say that HCPCS A9276, A9277, and A9278 are not covered codes.  The requested monitor is coded in such a way that makes it statutorily not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (A9276, A9277, A9278).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the three outpatient mental health visit you had from July 22, 2021, to September 15, 2021.  
You asked the Plan to waive the copayment for the outpatient mental health visits. You say that you had three visits with this provider and had to fill out a large packet of information.  
You stated that the psychologist told you that they do not treat adults, only children.  You stated that you would like your copayments returned. The Plan denied your request. The Plan says you were charged these copayments 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 $25 copayment per visit for outpatient mental health care. You have been asked to pay a $25 copayment per visit for the outpatient mental health visits. These copayments apply regardless of the outcome of those visits. 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 three outpatient mental health visit you had from July 22, 2021, to September 15, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from January 25, 2021, through January 28, 2021. 
You asked the Plan to pay for inpatient hospital care. The Plan denied your request. The Plan says even though the member revoke hospice during the inpatient stay of January 25, 2021 and January 28, 2021 the hospital admission belongs to Medicare fee for service.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on January 25, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided from January 25, 2021, through January 28, 2021.