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

We decided that the Plan does not have to pay for hearing aids provided on March 3, 2021.
You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says the contract with the Plan say 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.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plan's hearing aid provider. We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on March 3, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device (E0601).
You asked the Plan to pre-approve a CPAP device. You say that the item is medically necessary. The Plan denied your request. The Plan says you have not been compliant with your device.
The Plan must follow Medicare rules. Medicare rules say that you must use the PAP device for greater than or equal to 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device (E0601)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational
therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomics panel provided on May 28, 2021.
You asked the Plan to pay for the testing services. You say that the testing services were specifically requested
by the enrollee's physician. The Plan denied your request. The Plan says the procedure codes billed are not
valid for the services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We looked at the file and the rules. If a single procedure is performed, only one code with one unit of service
may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage of
the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the
pharmacogenomics panel provided on May 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination, chest (71046) provided June 15, 2021.
You asked the Plan to pay for the diagnostic services. You say that you did not know that there was going to be a charge for the radiological exam. You thought it was covered. you would not have gone and gotten the x-rays. The Plan denied your request. The Plan says the claim was processed with the correct cost share applied per the Evidence of Coverage.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $750 deductible which applies to Outpatient diagnostic tests and therapeutic services and supplies. The item or service you asked the Plan to pay for falls within the benefit category Outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible which applies to Outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time the diagnostic services was received on June 15, 2021. Therefore, we decided that the Plan does not have to pay for radiologic examination, chest (71046) provided June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for periodontal maintenance (D4910)
provided on June 9, 2021.
You asked the Plan to pay an additional amount for periodontal maintenance. You say that you do not agree
with the amount the Plan paid for the service at issue. The Plan denied your request. The Plan says the cost
shares were applied correctly for this service.
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 $50
copayment, a 75% coinsurance, and a $50 deductible for basic restorative dental services.
You have been asked to pay a $50 copayment, a 75% coinsurance, and a $50 deductible for periodontal
maintenance. Periodontal maintenance falls within the basic restorative dental 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 pay an additional amount for periodontal maintenance (D4910) provided on June 9,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the genicular nerve block provided on February 11, 2021.
You asked the Plan to pay for the services provided. You say that doing therapy was contraindicated. The Plan denied your request. The Plan says the effectiveness of the nerve block in the setting of knee osteoarthritis has not been demonstrated in peer-reviewed literature.
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 services provided. Our physician reviewer found that the enrollee has a diagnosis of osteoarthritis of the knee. Genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain. Therefore, the provided services were 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 services provided have not been met. Therefore, we decided that the Plan does not have to pay for the genicular nerve block provided on February 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure 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 procedure 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 Vertiflex procedure. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested procedure is not recommended by leading orthopedic societies. The procedure would be considered experimental/investigational at this time.

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services (93926) provided on May 11, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the ultrasound services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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 ultrasound services (93926) provided on May
11, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete dentures. You say that you lost your lower denture and broke your upper denture in half. You also say that you have a lot of health issues that have become worse with no teeth. The Plan denied your request. The Plan says these services exceed the maximum counts allowed per period.
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, complete maxillary denture (D5110) and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) and complete mandibular denture (D5120) on February 19, 2018 and your complete maxillary denture (D5110) and complete mandibular denture (D5120) benefits have been exhausted.
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eyelid repair procedure (67917) provided on June 23, 2021.
You asked the Plan to waive the copayment for an eyelid repair. You say that the price you are being charged is too high and you have paid less in years past. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. You have been asked to pay a $225 copayment for an eyelid repair. An eyelid repair falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an eyelid repair procedure (67917) provided on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services provided on March 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that you were unable to get the authorization before the service was done. 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 file shows the enrollee was seen for a monthly follow up and medication refills. 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 services. Therefore, we decided that the Plan does not have to pay for the pain management services provided on March 23, 2021, by an out-of-network (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. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted for treatment of esophageal complications from laryngeal cancer. The record indicates that the enrollee underwent a surgical procedure and had post-operative complications. The record indicates that she is receiving antibiotics until October 25. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.
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: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency room services provided on April 6, 2021.
You asked the Plan to pay for the services provided. You say that the modifier is appropriate. The Plan denied your request. The Plan says that the documentation did not support the adjustments.
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. We looked at the file and the rules. The case file does not contain the Plan's rationale or Medicare rules to explain and/or support their reasoning to deny services. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the emergency room services provided on April 6, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on April 27, 2021.
You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says this service is not covered out-of-network.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only through the Plan's hearing aid provider. We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve addition to lower limb prosthesis, vacuum pump.
You asked the Plan to pre-approve addition to lower limb prosthesis, vacuum pump. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that additions to lower limb prostheses are only covered for certain indications. 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 addition to lower limb prosthesis, vacuum pump. Our reviewer says that the documentation does not support that the requested item is medically reasonable or necessary. Our physician reviewer found the requested Blatchford Echelon Vacuum System appears to exceed the enrollee's medical need. The documentation does not reveal extenuating findings on the treatment physician medical progress notes that indicate a need for the Blatchford Echelon Vacuum System. The Blatchford Echelon Vacuum System is not proven more effective or than a standard socket for this enrollee's condition. Therefore, the enrollee does not meet criteria for the requested item. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of addition to lower limb prosthesis, vacuum pump have not been met. Therefore, we decided that the Plan does not have to pre-approve addition to lower limb prosthesis, vacuum pump.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 13, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that the laboratory services are not supported in the medical record. Specifically, "If a laboratory
procedure produces multiple reportable test results, only a single code shall be reported for the procedure. If
there is no code that describes the procedure, the laboratory shall report a miscellaneous or unlisted procedure
code with a single unit of service. Review of the file shows that the services rendered were billed with multiple
procedure codes. Based on this information, we decided that Medicare rules for coverage of the laboratory
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services
provided on May 13, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided from December 21, 2020, through March 17, 2021.
You asked the Plan to pay for the additional supplies and materials. You say that the medical records fully support and justify billing code 99072. You say that the daily notes show the kind of precautions taken and the code should be reprocessed for payment. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.
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, the CPT Code Manual definition of code 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.
We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided from December 21, 2020, through March 17, 2021.