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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there are no skilled nursing or skilled physical therapy needs requiring an inpatient skilled nursing facility level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive hearing loss panel provided on March 17, 2021.
You asked the Plan to pay for the comprehensive hearing loss panel. You say that you would like reconsideration based on the records submitted. 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.
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 comprehensive hearing loss panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Please note, the diagnosis submitted is not corroborated in the clinical documentation which was submitted. Therefore, we decided that the Plan does not have to pay for the comprehensive hearing loss panel provided on March 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 26, 2021, to February 24, 2021.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says skilled services were not necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from January 26, 2021, to February 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for after cataract laser surgery visits provided on December 10, 2020 and December 22, 2020.
You asked the Plan to waive the copayments for specialist visits. You say that according to a Plan representative these charges should not have been applied. The Plan denied your request. The Plan says the copayment amounts you are being charged are 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 $30 copayment for each specialist visit. There were 2 visits, resulting in a total copayment amount of $60.
You have been asked to pay $30 copayment for each specialist visit. Specialist visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for after cataract laser surgery visits provided on December 10, 2020 and December 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Percutaneous lysis of epidural adhesions (62264).
You asked the Plan to pre-approve the procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is experimental and non-covered.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found insufficient records were provided to support the requested service. Furthermore, the medical literature does not support the overall use of this procedure. It is considered investigational.
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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve Percutaneous lysis of epidural adhesions (62264).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular denture provided on June 22, 2020.
You asked the Plan to pay for the mandibular denture. You say that you would like to be reimbursed for this denture that you paid out of pocket for. The Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan also says that you had this service less than 60 months ago.
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, dentures are limited to once every 60 months. The record shows that you received a mandibular denture on March 18, 2019 and your mandibular denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the mandibular denture provided on June 22, 2020.
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 February 15, 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 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 February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and
pneumatic appliance (E0673) provided on July 2, 2020.
You asked the Plan to pay for an intermittent limb compression device and pneumatic appliance. You say that
The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for
prevention of deep vein thrombosis.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically
necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with
venous stasis ulcers.
The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous
stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression
device (E0675) and pneumatic appliance (E0673) provided on July 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee o January 26, 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 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 physician services provided to the enrollee o January 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

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

We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87541, 87581, 87640, 87798 and 87532) provided on July 16, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because you do not have any knowledge of the member's benefits prior to the specimen arriving at the lab. The Plan denied your request. The Plan says the place of service code billed on this claim is incorrect.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We find that CPT codes 87486, 87496, 87498, 87541, 87581, 87640, 87798 and 87532 are not supported in the record. Specifically, this claim was billed with the laboratory place of service code but the record indicates that the member's face-to-face service was rendered in a different setting. 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 laboratory services (87486, 87496, 87498, 87541, 87581, 87640, 87798 and 87532) provided on July 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the professional services for allergen immotherapy (95115) rendered by an out-of-network (OON) provider on March 4, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior 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. You are not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the professional services for allergen immotherapy (95115) rendered by an out-of-network (OON) provider on March 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage, per statute mile (A0425) provided September 4, 2020.
You asked the Plan to waive the copayment for the emergency ambulance transport. You say that you required the ambulance transport due to a coronavirus (COVID-19) diagnosis and therefore the copayment should be waived. The Plan denied your request. The Plan says the waiver for copays regarding COVID-19 diagnoses did not apply to ambulance services. 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 $225 copayment per ride for Medicare-covered ground and air ambulance services.
You have been asked to pay a $225 copayment for the emergency ambulance transport. This transport falls within the Ambulance services benefit category. The copayment waiver for COVID-19 does not apply to ambulance services. 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 ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage, per statute mile (A0425) provided September 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services provided on February 27, 2021 by an out-of-network provider.
You asked the Plan to pay for Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing (71275). You say that this service was medically necessary. The Plan denied your request. The Plan says you did not request prior authorization as required.
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the radiology services provided on February 27, 2021 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient clinic visit (G0463, 80048, 80061, 80076,
82607, 83036, 81001, 90670, 90715, G0009, 90472, 36415) provided on September 21, 2020, by an OON
provider.
You asked the Plan to pay for an outpatient clinic visit. You say that this was necessary because the enrollee
had recently moved. The Plan denied your request. The Plan says this was not 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 an outpatient clinic visit (G0463, 80048, 80061,
80076, 82607, 83036, 81001, 90670, 90715, G0009, 90472, 36415) provided on September 21, 2020, by an
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the complete series x-ray (D0210), filling (D2392) for tooth # 5, fillings (D2332) for teeth # 10 and 11, the filling (D2393) for tooth # 13, and scaling and root planing (D4341) for all 4 quadrants provided from February 10, 2021, to March 10, 2021.
You asked the Plan to pay for the dental services. You say that this provider was in network as your wife already went there. You say that you were advised you needed to have additional work done before March 10, 2021, or the services would not be covered. You say that now you have received a bill for the services you were told would be covered. You also say that you would not have had them done had you known they would not be covered. The Plan denied your request. The Plan says the provider in this case is not contracted with Medicare and therefore not contracted with the Plan. The Plan also says that dental services from a provider that is not in network are not covered.
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 and the services are listed as covered, dental services you receive out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the complete series x-ray (D0210), filling (D2392) for tooth # 5, fillings (D2332) for teeth # 10 and 11, the filling (D2393) for tooth # 13, and scaling and root planing (D4341) for all 4 quadrants provided from February 10, 2021, to March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on March 1, 2021.
You asked the Plan to pay for this service. 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 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 physician services provided to the enrollee on March 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker purchased out of network on February 19, 2021.
You asked the Plan to pay for out of network equipment. You say that you needed a walker, and this should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan durable medical equipment requires prior authorization and should be purchased in network. The provider in this case is not a network provider. The Plan did not pre-approve this item. Therefore, we decided that the Plan does not have to pay for a walker purchased out of network on February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant removal (D6100) provided on May 5, 2021.
You asked the Plan to pay for the implant removal (D6100). You say that if the implant was not removed you would lose bone and develop an opening for infection. You say that the removal was medically necessary, and the claim should be reconsidered. The Plan denied your request. The Plan says the service is 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the implant removal (D6100) provided on May 5, 2021.