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

 We decided that the Plan does not have to pre-approve a bone scan for the enrollee.  You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says there is insufficient evidence that the requested service is reasonable and necessary and is being used to improve the functioning of a malformed body member.  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 scan. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the bone scan that was requested is typically performed to evaluate for primary or metastatic bone tumors. In this case, the submitted diagnosis for the bone scan request was right shoulder primary osteoarthritis. There is no justification for a bone scan for this diagnosis.    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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a bone scan for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).  You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that the use of a basic compression pump had been tried and was quickly ruled out due to the enrollee's unique characteristic of pain and truncal swelling. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physical exam (99396) provided on August 3, 2021.  You asked the Plan to pay for the physical exam. You say that you would like reconsideration for the denied claim. The Plan denied your request. The Plan says you have exceeded limits set in the subscriber agreement.  The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. The Health Plan offers an additional benefit for an annual routine physical exam.   Based on review of the file, an annual physical exam was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the physical exam (99396) provided on August 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753).  You asked the Plan to pre-approve the unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753). You say that the science supporting this treatment is far great than many other procedures coverage is provided. You say that this procedure fills a treatment gap for patients who do not receive adequate relief from traditional conservative methods and the procedure should be authorized. The Plan denied your request. The Plan says Medicare does not cover unproven and not medically necessary procedures due to insufficient evidence of efficacy.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.      We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure remains experimental, and 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 unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753) have not been met. Therefore, we decided that the Plan does not have to pre-approve the unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the power wheelchair to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the power wheelchair. You say that a power wheelchair is medically necessary. The Plan denied your request. The Plan says the 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 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 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 the power wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral to an out-of-network ophthalmology provider.  You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical need shown as to why these services cannot be received in-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 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 a referral to an out-of-network ophthalmology provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the WIDEX Moment 440 Rechargeable Hearing aid.  You asked the Plan to pre-approve the WIDEX Moment 440 Rechargeable Hearing aid. The Plan denied your request. The Plan says the WIDEX Moment 440 Rechargeable Hearing aid is not a covered hearing device.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the Plan hearing aid benefit does not cover the WIDEX Moment 440 Rechargeable Hearing aid. Therefore, we decided that the Plan does not have to pre-approve the WIDEX Moment 440 Rechargeable Hearing aid.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the magnetic resonance imaging, any joint of lower extremity, (right ankle) (73721).  You asked the Plan to pre-approve the diagnostic service. You say that you are requesting an appeal for the denied MRI of the right ankle without contrast, 73721. The Plan denied your request. The Plan says the enrollee does not meet the criteria for an imaging study. The appeal documents do not show that the enrollee has tried and failed at least 6 months of conservative treatment for the foot pain.  The Plan must follow Medicare rules. Medicare rules say that MRIs 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 diagnostic service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic heel pain from plantar fasciitis who was treated with PT, cortisone, icing, NSAIDs, immobilization, orthotics, surgery, and night splints. An MRI right ankle without contrast was requested. Although the enrollee's records show that the enrollee had tried the above treatments, there was insufficient evidence of these methods having been tried for at least 6 months together with failure to help justify MRI at this time. Also, there was no planned procedure that required this imaging. Therefore, this request for MRI will be considered not medically necessary at this time.   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 diagnostic service have not been met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance imaging, any joint of lower extremity, (right ankle) (73721).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the tympanometry and reflex threshold measurements (92550) and the comprehensive audiometry threshold evaluation and speech recognition (92557) rendered by the out-of-network (OON) provider on June 23, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the tympanometry and reflex threshold measurements (92550) and the comprehensive audiometry threshold evaluation and speech recognition (92557) rendered by the out-of-network (OON) provider on June 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the manual wheelchair (K0009) and sales tax (S9999), provided on June 5, 2021.  You asked the Plan to pay for the wheelchair and tax. You say that the items were medically necessary. The Plan denied your request. The Plan says you obtained this item through a provider that is not enrolled in Medicare and sales tax is not a covered benefit.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.      Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the manual wheelchair (K0009) and sales tax (S9999), provided on June 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on August 30, 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.  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 (99214) rendered by the out-of-network (OON) provider on August 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost share for a wheelchair (K0898) and sales tax (S9999), provided on July 30, 2021.  You asked the Plan to waive the cost share for a wheelchair and sales tax. You say that the items should be covered. The Plan denied your request. The Plan says the cost share was 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 20% coinsurance for durable medical equipment (DME) and related supplies.   You have been asked to pay a 20% coinsurance for a wheelchair and sales tax. These items fall within the durable medical equipment (DME) and related 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 cost share for a wheelchair (K0898) and sales tax (S9999), provided on July 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for occupational therapy services provided on May 21, 2021.  You asked the Plan to waive the copayment for the occupational therapy. You say that the provider is in-network. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $55 copayment for each out-of-network occupational therapy visit.   The file shows that this provider was not contracted with the Plan on May 21, 2021. Therefore, you have been asked to pay a $55 copayment for the occupational therapy. Occupational therapy falls within the Outpatient Rehabilitation Services benefit category.  This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for occupational therapy services provided on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intravitreal injection of a pharmacologic agent (67028), injection, bevacizumab (J9035), and scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina (92134) provided August 11, 2021.  You asked the Plan to pay for the eye injection, bevacizumab and ophthalmic diagnostic imaging. You say that this was an emergency situation. The Plan denied your request. The Plan says out-of-network services for a foreseen condition is not covered 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the intravitreal injection of a pharmacologic agent (67028), injection, bevacizumab (J9035), and scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina (92134) provided August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (87496, 87498, 87631, 87798, 87486, 87541, 87581 and 87640) provided on June 26, 2020.  You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim was not billed with the appropriate place of service code.  The Plan must follow Medicare rules. Medicare rules 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, the claim was billed with the laboratory place of service code but the records indicate that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (87496, 87498, 87631, 87798, 87486, 87541, 87581 and 87640) provided on June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) and pin retention - per tooth, in addition to restoration (D2951) provided September 17, 2021.  You asked the Plan to pay for the porcelain/ceramic crown and pin retention. You say that your Annual Notice of Change and a plan representative indicated that crowns would be covered. The Plan denied your request. The Plan says these services are not covered under your benefits.  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 crown - porcelain/ceramic (D2740) and pin retention - per tooth, in addition to restoration (D2951) provided September 17, 2021.   Your complaint about potentially being provided incomplete or incorrect information is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a gingival flap procedure (D4241) to be provided by an out-of-network provider.  You asked the Plan to pre-approve a gingival flap procedure. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says D4241 is not a covered benefit procedure.  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 pre-approve a gingival flap procedure (D4241) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the fundus photography with interpretation and report (92250) and the ophthalmological medical examination and evaluation (92004) rendered by the out-of-network (OON) provider on July 29, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the fundus photography with interpretation and report (92250) and the ophthalmological medical examination and evaluation (92004) rendered by the out-of-network (OON) provider on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the advance care planning (99497) provided on June 17, 2021.  You asked the Plan to pay for code 99497. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99497 is a column II code to column I code 99223. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the advance care planning (99497) provided on June 17, 2021.