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 May 25, 2021.
You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says hearing aids ordered through providers other than the Plan's hearing aid provider are not covered.
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 ordered through the Plan's hearing aid provider. We looked at the file and the Plan's rules. The file shows that that 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 May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology testing provided on May 14, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the cytopathology testing. You say that you are an ancillary provider and unable to obtain a prior authorization. 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 there was no referring provider. Therefore, we decided that the Plan does not have to pay for the cytopathology testing provided on May 14, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral periapical X-rays (D0220, D0230) provided on June 25, 2021.
You asked the Plan to pay for intraoral periapical X-rays. You say that the services at issue should be covered by the Plan as all dentists are using these kinds of X-rays for good dental preventative care. The Plan denied your request. The Plan says the services at issue are not a covered benefit.
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 services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for intraoral periapical X-rays (D0220, D0230) provided on June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator.
You asked the Plan to pre-approve the services. You say that the enrollee has disc bulges at multiple levels of their lumbar spine that is causing lumbar radiculopathy. The Plan denied your request. The Plan says the enrollee has not had maximal medical management and there is no adequate documentation of any form of neurosurgical evaluation that indicate that the enrollee is not a surgical candidate.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has degenerative low back pain. All treatment options and measures have not been tried yet. A stimulator for degenerative low back pain is not an approved procedure and not medically needed. 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio (J3380).
You asked the Plan to pre-approve Entyvio. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. 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 Entyvio. Our reviewer says that the requirements for coverage of Entyvio have not been met. Our physician reviewer found the Plan requires a trial of drug Stelara and either Remicade or Inflectra before they will approve the requested drug. The records do not show that the enrollee has tried these drugs, that they would be less effective, or that they would likely have adverse effects. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio (J3380).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (99212) provided June 17, 2021.
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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 CPT code 99212 is not supported in the medical record. Specifically, payment for this service is bundled in payment for the primary anesthesia service. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99212) provided June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy of the device. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam and refraction provided on January 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON optometry services. You say that the services should be covered. The Plan denied your request. The Plan says these non-emergency services were provided out of network without 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 eye exam and refraction provided on January 18, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for SelectMDx genetic testing provided on April 13, 2021.
You asked the Plan to pay for genetic testing. You say that this testing is used to help distinguish patients at increased risk for clinically significant prostate cancer from those at very low risk for aggressive disease. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because screening services without a valid medical diagnosis related to the health of the enrollee are not a benefit.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. This testing was ordered by an in-network provider, who attested to the medical necessity and non-screening purpose of this testing. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for SelectMDx genetic testing provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vitamin B-12 injection services provided on April 2, 
2021. 
 
You asked the Plan to pre-approve the Vitamin B-12 injection services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered were not medically 
necessary. 
 
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 Vitamin B-12 injection services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee was diagnosed with fatigue. The provided records do not 
clearly show a B12 deficiency or reason for not using oral vitamin B12 to help justify a vitamin B12 injection. 
Therefore, the enrollee did not meet criteria for the services rendered. 
 
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 Vitamin B-12 injection services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Vitamin B-12 injection services provided on April 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by genetic testing provided on September 2, 2020, billed with codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640 and 87798.
You asked the Plan to pay for the genetic infectious agent testing. You say that this is medically necessary. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the genetic infectious agent testing have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by genetic testing provided on September 2, 2020, billed with codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640 and 87798.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compressor device (E0651) segmental pneumatic appliance (E0667) provided September 23, 2020.
You asked the Plan to pay for the pneumatic compressor device and appliance. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, and there were no valid delivery documents submitted.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. There is also no evidence of an established relationship between the enrollee and the ordering physician. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for pneumatic compressor device (E0651) segmental pneumatic appliance (E0667) provided September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (procedure code 29075) provided to the enrollee
on June 2, 2020.
You asked the Plan to pay for the services. You say that the services should be paid for. The Plan denied your
request. The Plan says despite multiple attempts, clinical records were not received.
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 29075 is "Application, cast; elbow to finger (short arm)."
We find that CPT code 29075 is not supported in the medical record. Specifically, despite multiple documented
attempts by the plan to receive medical records, none were received. Without these records, the code cannot be
verified or substantiated. 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 pay for the services
(procedure code 29075) provided to the enrollee on June 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional units of the laboratory services (88347) provided on January 21, 2021.
You asked the Plan to pay for the additional units of laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the billed units exceed Medicare's Medically Unlikely Edit Value.
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 additional units of laboratory services. Our reviewer says that the documentation does not support that the additional 3 units of 88347 were medically reasonable or necessary. Our physician reviewer found the review has determined that the there is no specific clinical rationale for the requested additional 3 units of 88347. 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 additional units of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the additional units of the laboratory services (88347) provided on January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services coded as
92134, 67028, 67210 and 11720 provided May 12, 2021 to July 7, 2021.
You asked the Plan to waive the copayment for the outpatient services. You say that you paid the $25
deductible at the time of service. You received fees for the room that you were seen in. You were never
charged these fee's before and you were not informed at the time of service of a fee for a room. The Plan denied
your request. The Plan says the claims were processed with the correct cost share's applied per the Evidence of
Coverage.
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 $275
copayment for Medicare covered outpatient hospital and observation services $25 copayment for Medicare
covered non-radiological outpatient diagnostic procedures and tests.
You have been asked to pay $649 ($25 + $25 + $275 + $275 + $49) for the outpatient services. The outpatient
services fall within the Outpatient hospital services benefit category. This means that you have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for the outpatient hospital services coded as 92134, 67028, 67210 and 11720 provided May 12,
2021 to July 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xtandi.
You asked the Plan to pre-approve Xtandi. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 pre-approve Xtandi.
Benefits for Xtandi 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on April 14, 2021, to April 30, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you feel the service should be covered because you were hospitalized for over 10 days and the copayments should be waived. The Plan denied your request. The Plan says the copayment you are being charged 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 $285 copayment per day, for days 1 to 7 and a $0 copayment per day, for days 8 to 90, for inpatient hospital care.
You have been asked to pay a $285 copayment for inpatient hospital care. The records show that you were
inpatient for sixteen (16) days. The EOC confirms $285 per day is the required copayment for this service.
Your total cost share responsibility is $1,995 ($285 x 7 days = $1,995). 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 provided on April 14, 2021, to April 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self administered drugs provided in an outpatient setting from April 13, 2021, to April 14, 2021.
You asked the Plan to pay for the self administered drugs. You say that you were not allowed to give yourself insulin shots. You say that you were not able to use your hands. You also say that the drugs should be covered.
The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
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 in an outpatient setting from April 13, 2021, to April 14, 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: 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 enrollee's current needs cannot safely be met at a 
lower level of care. The Plan denied your request. The Plan says the notes do not demonstrate that the enrollee 
can be expected to actively participate in, and benefit significantly from, the intensive rehabilitation therapy 
program which generally consists of at least 3 hours of therapy per day at least 5 days per week. 
 
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. 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. There is not a reasonable expectation that the enrollee will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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.