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

We decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81411, 81439, 81238, 81404, 81407, and 81408) provided to the enrollee on December 14, 2020.
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 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. The enrollee had cardiovascular risk assessment testing on December 14, 2020. 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): 81411, 81439, 81238, 81404, 81407, and 81408) provided to the enrollee on December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic consultation with a dentist or physician other than the requesting dentist or physician (D9310) provided on May 13, 2021.
You asked the Plan to pay for the diagnostic consultation. You say that you did not realize this service would not be covered, and you feel the cost is too high for the few minutes you were seen. The Plan denied your request. The Plan says this service is not covered by your dental 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 a diagnostic consultation with a dentist or physician other than the requesting dentist or physician (D9310) provided on May 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation device 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 this service is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulators are electro-acupuncture devices which are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network provider.
You asked the Plan to pre-approve a consultation with an out-of-network provider. You say that the requested provider has successfully done the type of surgery the enrollee is requesting. The Plan denied your request. The Plan says the procedure the enrollee wants its not covered by Medicare and treatment is available within the network.
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. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. The desired procedure is not covered by Medicare. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral or facial photograph images (D0350 x 4) provided on May 14, 2021.
You asked the Plan to pay for the dental services. You say that you were not told in advance that these photographs would be necessary for a first-time visit. You say that you were never shows these photographs. You also say that you do not feel that you should pay for these photographs. The Plan denied your request. The Plan says benefits are determined based on how they are billed. The Plan also says that the 2D oral or facial photograph images are not listed as covered service.
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 2D oral or facial photograph images are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral or facial photograph images (D0350 x 4) provided on May 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and full mouth xray
(D0210) provide don May 26, 2021.
You asked the Plan to pay for the dental services. You say that had a cleaning and x-ray. You say that these
services are covered under your plan. You also say that you do not understand why the services were denied.
The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 36 months. The
Plan says that 1 full mouth x-ray is covered every 5 years. The Plan also says that the frequency limits for these
services have been exceeded.
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,
the frequency limits have been exceeded. The record shows that the Plan paid for these services that you
received on February 20, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive
oral evaluation (D0150) and full mouth x-ray (D0210) provide don May 26, 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.
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 your ongoing skilled therapy and nursing needs can be provided at a
lower level of care.
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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for pneumonia and an infected right knee prosthetic and were discharged to skilled nursing facility on September 11, 2021. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on April 27, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 71045 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 71045 (chest x-ray, one view) and 71046 (chest x-ray, two views). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 71046.
Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 13, 2021 by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid.
The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care
physician. The Plan says that the referring provider is out-of-network.
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 physician services provided on April 13, 2021 by
an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a
participating provider on April 23, 2021.
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you should not have a
copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225
copayment for outpatient surgery/in-network.
You have been asked to pay a $225 copayment for a diagnostic colonoscopy. Evidence was provided to show
that polyps were found and removed. The rules say that, if during the course of the screening colonoscopy, a
lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic
procedure classified as a colonoscopy with biopsy or removal should be billed. A diagnostic colonoscopy falls
within the outpatient surgery/in-network 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 a 
diagnostic colonoscopy provided by a participating provider on April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that the enrollee has mental health issues which make it difficult for him to prick his fingers as often as needed to monitor his blood sugar. The Plan denied your request. The Plan says the enrollee's blood sugar control is currently good, and there is no documentation of three times daily insulin use.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily administrations. Although the use of a CGM may be appropriate given the enrollee's condition, this is not a Medicare-covered indication for use of a CGM. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Cimzia.
You asked the Plan to pre-approve Cimzia. You say that you feel this drug should be covered. The Plan denied your request. The Plan says that the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that the case file was submitted to Maximus without the appropriate medical records necessary to review this drug for medical necessity. Without this required information, there is no documentation in the case file to show that the enrollee does not meet criteria for the requested drug at this time. In addition, the requesting physician is a contract provider with the Plan. Medicare rules say that a contract provider is an agent of the plan. Therefore, we decided that the Plan has to pre-approve Cimzia.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for screening mammography (77067) and screening digital tomosynthesis for mammography (77063) provided April 15, 2021.
You asked the Plan to pay for the diagnostic services. You say that your doctor requires you to have annual mammograms in order to monitor a condition. The mammographer did not accept the Plan so you paid out of pocket. You have out of network coverage and do not understand why this is denied. The Plan denied your request. The Plan says the services are non-covered as the provider opted out of Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for screening mammography (77067) and screening digital tomosynthesis for mammography (77063) provided April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on December 8, 2020.
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. The 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 this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on December 8, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99203) provided on
January 8, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 $35
copayment for services obtained from a specialist, or under certain circumstances, treatments by a nurse
practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You have been asked to pay a $35 copayment for the specialist office visit provided. 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 office visit (99203) provided on January 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 multiple power wheelchair with power tilt coded as K0861, E0955, E1007, E1028, E2311, E2313, E2313, E2361, E2377, E2607, E2620.
You asked the Plan to pre-approve the group 3 power wheelchair. You say that please review and approve all
codes as a purchase. The Plan denied your request. The Plan says the criteria for medical necessity has not been
met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 group 3 power wheelchair. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found in this case, the enrollee has a neurologic disorder with functional deficits.
She meets criteria for use of a power mobility device and has been supplied with a group 2 PWC as recently as
November 2020. The requested group 3 PWC with accessories are not medically necessary as she does have
use of her hands and can operate and control the power options using the switches that are included in the basic
wheelchair. Furthermore, the documentation does not indicate that the member has any pressure injuries or
requires intermittent catheterization of the bladder.
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 group 3 power wheelchair have not been met. Therefore, we decided that the
Plan does not have to pre-approve a group 3 multiple power wheelchair with power tilt coded as K0861,
E0955, E1007, E1028, E2311, E2313, E2313, E2361, E2377, E2607, E2620.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device.
You asked the Plan to pre-approve a CPAP device. You say that this device is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that medical records must be submitted to confirm that Medicare coverage criteria have been met. 
We looked at the file and Medicare rules. In this case, no medical records were submitted to support that the criteria for coverage have been met. The Plan confirmed that they sent several requests for relevant medical records that were not returned. Based on this information, we decided that Medicare rules for coverage of a CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from March 5, 2021, to
March 8, 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 the enrollee
required no nursing services which would be considered skilled services by Medicare.
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 March 5, 2021, to March 8, 2021.