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

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on April 23, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that your dentist has always accepted your dental insurance. You also say that you did not realize there were different dental plans, but knew you were entitled to two cleanings per year. The Plan denied your request. The Plan says these services are not covered benefits when rendered by a dentist who does not participate in the Plan's program.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on April 23, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and urinalysis provided on May 27, 2021, by
an OON provider.
You asked the Plan to pay for the office visit and urinalysis. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when
provided 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 must pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the office visit and urinalysis provided on May 27,
2021, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on May 17, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that you believe the ambulance services should be considered urgently needed care and be covered. The Plan denied your request. The Plan says since there was no transport, the ambulance charges are not covered.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 17, 2021. 

The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on May 17, 2021.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is able to get the necessary rehabilitation at the skilled nursing level of care with the goal of safely returning member to home.
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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for thoracic spine surgery for spinal stenosis and vertebral fractures after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 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. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Botox treatment (J0585).
You asked the Plan to pre-approve the Botox treatment. You say that the Botox treatment is necessary. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria
The Plan must follow Medicare rules. Medicare rules say that Botox injections are only covered for certain indications. Neither the LCD nor the Compendia supports the treatment of gastroparesis with Botox injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Botox treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve the Botox treatment (J0585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the expandable controller (E2377), harness (E2313),
and connection (E2311).
You asked the Plan to pre-approve the expandable controller, harness and connection.. You say that the item is
medically necessary. The Plan denied your request. The Plan says the items are 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 expandable controller, harness and
connection. Our reviewer says that the requested items are not considered medically reasonable and necessary
in this case. Our physician reviewer found that although there are three approved power options on this
wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options
through the joystick. Documentation shows that the member is modified independent with bathing and
grooming, independent with feeding (with set up). Member's upper limb strength and function are adequate for
the member to be able to control the power options using their own switches which are included in the
allowance of these power options.
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 expandable controller, harness and connection. have not been met.
Therefore, we decided that the Plan does not have to pre-approve the expandable controller (E2377), harness
(E2313), and connection (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telemedicine services provided to the enrollee from May 11, 2021 to June 1, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says services rendered by a non-participating provider must be authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for telemedicine services provided to the enrollee from May 11, 2021 to June 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT calcium scoring test (75571).

You asked the Plan to pre-approve CT calcium scoring. You say that the requested procedure is a medical necessity for you. 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 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 CT calcium scoring. Our reviewer says that the requested service is not a covered benefit. Our physician reviewer found that a lipid profile is not included. You have no symptoms of cardiovascular disease. AS such, the requested service is not covered. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT calcium scoring have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT calcium scoring test (75571).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on March 2, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 out of network physician services provided to the enrollee on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99233) provided on February 15, 2021.

You asked the Plan to pay for hospital care. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with an appropriate primary diagnosis.

The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation.

We looked at the file and Medicare rules. The billed primary, first-listed diagnosis, F05, delirium due to known physiological condition, is a manifestation code that requires the underlying condition to be sequenced first. Based on this information, we decided that Medicare rules for coverage of hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99233) provided on February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options and components/accessories.

You asked the Plan to pre-approve Group 3 power wheelchair with multiple power options. You say that the wheelchair and all of the components are required by the enrollee to meet her medical, functional, and mobility needs throughout the day. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because although the enrollee meets criteria for a Group 3 power wheelchair with no power options, the enrollee does not meet criteria for a power tilt/recline and therefore does not meet criteria for the base Group 3 power wheelchair with multiple power options.
The Plan follows Medicare rules. Medicare rules state that a Group 3 power wheelchair with multiple power options may be covered if certain clinical criteria are met. 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 Group 3 power wheelchair with multiple power options. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested Group 3 power wheelchair with multiple power options. Our physician reviewer found the requested Group 3 power wheelchair with multiple power options is not medically necessary. The enrollee does not use a ventilator mounted to the wheelchair and does not meet coverage criteria for a power tilt and power recline seating system. There is no evidence of intermittent catheterization, spasticity, or evidence of being high-risk for a pressure ulcer. While the enrollee may have a qualifying Group 3 diagnosis and a mobility deficit that impairs mobility-related activities of daily living (MRADLs), the requested wheelchair exceeds the enrollee's medical needs. We looked at this physician's review, the file, and Medicare rules. The enrollee does not meet the criteria for a base Group 3 power wheelchair with multiple power options; therefore, the related accessories in this request are also denied. Based on this information, we decided that Medicare rules for coverage of Group 3 power wheelchair with multiple power options have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options and components/accessories.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on May 30, 2021.
You asked the Plan to waive the copayment for emergency care. You say that you were incorrectly diagnosed and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided on May 30, 2021.
We note your complaint you were misdiagnosed. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and laboratory test provided on May 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for office visit and lab test. You say that you have been seeing this doctor since 1998 and were under the impression that they would continue to be covered until June 1, 2021. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not 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 an office visit and laboratory test provided on May 18, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.
You asked the Plan to pre-approve seat lift mechanism. You say that a lift chair or mechanism is not a luxury but a necessity because of your serious falls. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because you do not have a diagnosis of severe arthritis of the hip or knee or severe neuromuscular disease.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met. 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 seat lift mechanism. Our reviewer says that you do not meet the Medicare criteria for a seat lift mechanism. Our physician reviewer found the documentation does not include objective imaging evidence of severe arthritis of the hip and/or neuromuscular disease. Your medical progress notes do not include a seat lift in the course of treatment. This seat lift is not likely to effect improvement in your condition or stop/slow deterioration in your condition. The records do not show that you are totally incapable of standing from a chair in the home.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve drugs and treatment in a phase 1 clinical trial.

You asked the Plan to pre-approve drugs and treatment in a phase 1 clinical trial. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. 

In this case, you asked the Plan to pre-approve drugs and treatment as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve drugs and treatment in a phase 1 clinical trial.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmic diagnostic imaging provided on June 7, 2021.
You asked the Plan to waive the copayment for ophthalmic diagnostic imaging. You say that you paid the $45 copayment for the office visit and disagree with the additional charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 for outpatient diagnostic tests. You have been asked to pay the allowed amount of $48.06, which is less than the $50 copayment for ophthalmic diagnostic imaging. Ophthalmic diagnostic imaging falls within the outpatient diagnostic tests and therapeutic services and supplies 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 ophthalmic diagnostic imaging provided on June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment received on January 22, 2021.
You asked the Plan to pay for the services. You say that you want to use your in-network benefits to cover this.
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 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 durable medical equipment received on January
22, 2021.