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

We decided that the Plan does not have to waive the copayment for the ophthalmological services: medical
examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient
(92004) provided March 5, 2021.

You asked the Plan to waive the copayment for the medical eye exam. You say that you believe you should be
charged a $0 copayment for a routine eye exam. The Plan denied your request. The Plan says the copayment
has been 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 $45
copayment for Vision Care.

You have been asked to pay a $45 copayment for the medical eye exam. This medical eye exam falls within the
Vision 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 ophthalmological
services: medical examination and evaluation with initiation of diagnostic and treatment program;
comprehensive, new patient (92004) provided March 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from April 29, 2021 through May 11, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you have no knowledge of self-administered drugs and the denial should be investigated. The Plan denied your request. The Plan says self-administered drugs are not covered under the medical benefits of the Plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from April 29, 2021 through May 11, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve application of a modality to 1 or more areas; electrical stimulation (CPT code 97014) and CMT; spinal, 1-2 regions (CPT code 98940) provided from April 8, 2021, through April 12, 2021, by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that you were told that as long as the doctor adjusted your back with their hands and no machine, that it would be covered by the health plan. The Plan denied your request. The Plan says this provider is not in-network and there are providers that could have provided the service.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. Review of the file show that you received services from April 8, 2021, through April 12, 2021, by an out-of-network provider. CMT; spinal, 1-2 regions (CPT code 98940) could have been performed by an in-network chiropractor. Furthermore, application of a modality to 1 or more areas; electrical stimulation (CPT code 97014) is not covered under your contract under any normal circumstances. The health plan contract says covered services include: Manual manipulation of the spine to correct subluxation (when one or more of the bones of your spine move out of position). Excluded from Medicare coverage is any service other than manual manipulation for the treatment of subluxation. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve application of a modality to 1 or more areas; electrical stimulation (CPT code 97014) and CMT; spinal, 1-2 regions (CPT code 98940) provided from April 8, 2021, through April 12, 2021, by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services billed with PDPM NDXF1x12 and provided on March 1, 2020, through March 14, 2020.
You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation received does not support all the items in Section GG to calculate the PDPM score billed.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. We asked our coder 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 SNF services. Our reviewer says that the submitted documentation does not meet criteria for reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to support billing NDXF1x14 days to the health plan, therefore this service cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services billed with PDPM NDXF1x12 and provided on March 1, 2020, through March 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing (CPT code(s): 81407, 81408, 81162, 81479 and 81437) provided to the enrollee on February 11, 2021, by an out-of-network provider.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says molecular genetic hereditary predictive screening testing is not a Medicare benefit for the diagnoses as listed on the claim and are done for screening purposes.

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. 

The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing (CPT code(s): 81407, 81408, 81162, 81479 and 81437) provided to the enrollee on February 11, 2021, by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty (20) additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you need assistance with transportation to upcoming medical appointment and no family, friends or neighbors to be able to assist you with transportation. The Plan denied your request. The Plan says you exhausted your benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of forty-eight (48) one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, this request
exceeds your benefit. Your 2021 EOC says you are covered for up to forty-eight (48) one-way trips are covered per calendar year (limited to ground transportation only). Therefore, we decided that the Plan does not have to pre-approve twenty (20) additional routine transportation trips
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a wig (A9282) received on November 10, 2020.

You asked the Plan to pay for a wig. You say that the item is medically necessary. The Plan denied your request. The Plan says the item at issue is not a covered benefit.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. 

In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig (A9282) received on November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214).
You asked the Plan to pre-approve a partial lower denture. You say that the requested item is a medical
necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because
the requested partial lower denture is not medically necessary.
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 a partial
lower denture when the services are medically necessary and reasonable.
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 partial lower denture. Our reviewer
says that the requested item is not medically necessary. Our physician reviewer found that it appears there is no
space available, or need for, replacement teeth on the lower arch. The lower arch is in full occlusion with the
upper dentition. As there are effectively no missing teeth on the lower arch, and currently full occlusion against
the upper arch with 16 points of posterior contacts, there would be no medical necessity for a partial lower
denture.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of a partial lower denture have not been met. Therefore, we decided that the Plan
does not have to pre-approve a partial lower denture (D5214).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to preapprove the acute inpatient hospital care.
You asked the Plan to preapprove acute inpatient hospital care. You say that inpatient authorization is medically necessary. The Plan denied your request. The Plan says it will overturn the total shoulder arthroplasty but uphold the inpatient hospital stay determining it was not medically necessary.
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 preapprove acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this
case. Our physician reviewer found the planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. 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. Therefore, we decided that the Plan does not have to preapprove the acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for pickleball classes for 2020.

You asked the Plan to pay for pickleball. You say that this fee should be covered by this benefit because the facility where the classes take place also has workout equipment. The Plan denied your request. The Plan says the fee at issue is only indicated for the sports classes. Sports fees are not covered by your health and wellness benefit.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's health and wellness benefit does not cover membership fees you pay to non-qualified health clubs or fitness facilities, including but not limited to, martial arts centers, gymnastics facilities, country clubs, sports clubs and social clubs, and for sports activities such as golf and tennis. The Plan's rules for coverage of gym benefits have not been met because the cost at issue is indicated as being a sports activities fee. Therefore, we decided that the Plan does not have to pay for pickleball classes for 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT
code(s): 22869 and C1821).

You asked the Plan to pre-approve the services. You say that you need this procedure to relieve back pain. The
Plan denied your request. The Plan says the services are considered experimental and 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 the services. 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex Superion device placement surgery (CPT code(s): 22869 and C1821).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the SNF services billed with PDPM NDXF1 x 12 and rendered on February 18, 2020, through February 20, 2020.

You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says The documentation received does not support all the items in Section GG to calculate the PDPM score billed.

The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. We asked our coder 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 SNF services. Our reviewer says that NDXF1 x 12 days does not meet criteria for reimbursement.

Our reviewer found the medical records provided do not include sufficient documentation to support billing NDXF1x12 days to the health plan, therefore this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the SNF services billed with PDPM NDXF1 x 12 and rendered on February 18, 2020, through February 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Proctofoam HC.

You asked the Plan to pre-approve Proctofoam HC. You say that the requested drug is a medical necessity for
the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drug requested here is not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Proctofoam HC.

Benefits for Proctofoam HC 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81439, 81408, 81407 and 81291) provided to the enrollee on January 28, 2021, by an out-of-network provider.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered.
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. Review of the file shows that enrollee had cardiovascular risk assessment testing on January 28, 2021. The denial remains upheld as non-covered as Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81439, 81408, 81407 and 81291) provided to the enrollee on January 28, 2021, by an out-of-network 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 LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care.
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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management services (99223 and 99356) provided on April 23, 2021.
You asked the Plan to pay for the evaluation and management services. You say that you would like reconsideration because the documentation supports the services billed. The Plan denied your request. The Plan says these services are considered to be part of the global surgery package.
The Plan must follow Medicare rules. Medicare rules say that visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the evaluation and management services have not been met. Specifically, the record indicates that a minor surgery procedure was billed and paid to the same provider for the same date of service. The billed
services are not separately reimbursable. Therefore, we decided that the Plan does not have to pay for the evaluation and management services (99223 and 99356) provided on April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional acupuncture visits.

You asked the Plan to pre-approve the visits. You say that additional acupuncture would be beneficial to your quality of life. The Plan denied your request. The Plan says this is not a covered for cervical spine pain.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, there is no benefit for cervical spine pain. Therefore, we decided that the Plan does not have to pre-approve additional acupuncture visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography, soft tissue neck; with contrast material(s) (CPT code 70491), for the enrollee.
You asked the Plan to pre-approve the CT scan. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our physician reviewer found the reviewed documentation indicates that state that the enrollee has complaints of throat pain and a feeling of tightness around their throat. The enrollee recently had a throat infection for which they took a course of Amoxicillin. The enrollee's doctor wanted to examine their throat with a scope, but the enrollee declined. The physical examination was normal. There is no specific clinical rationale for the requested CT scan. The enrollee would benefit from an ears, nose and throat (ENT) evaluation. The review has determined that the requested CT Scan 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 the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography, soft tissue neck; with contrast material(s) (CPT code 70491), for the enrollee.