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

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), prophylaxis (D1110), preventive procedure (D1999), and resin-based composite (D2392) provided on May 10, 2021, and May 24, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the comprehensive periodontal evaluation, prophylaxis, preventive procedure, and resin-based composite. The Plan denied your request. The Plan says these services were rendered by a provider who chose not to receive Medicare funds.
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 by a provider who has opted out of Medicare.
Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), prophylaxis (D1110), preventive procedure (D1999), and resin-based composite (D2392) provided on May 10, 2021, and May 24, 2021 by a Medicare opt out provider.
Appeal type: Testing
Decision: Unfavorable

we decided that the Plan does not have to pay for the ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) (CPT code 76705) provided to the enrollee on June 1, 2021.
You asked the Plan to pay for the ultrasound. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Our records indicate a NCCI Procedure to Procedure (PTP) edit exists between 76705 and 93976. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for the ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) (CPT code 76705) provided to the enrollee on June 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-sterile gloves (A4927).
You asked the Plan to pre-approve non-sterile gloves. You say that the requested item is a necessity for the enrollee's care. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve non-sterile gloves (A4927).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty power mobility device (K0108).
You asked the Plan to pre-approve the heavy duty power mobility device. You say that you are uncomfortable in your current PMD. The Plan denied your request. The Plan says you do not meet the requirements for the heavy duty PMD.
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. The rules also say that a Heavy Duty POV is covered for a beneficiary weighing 285 - 450 pounds.
The file shows that you do not meet the weight requirement for this device. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty power mobility device (K0108).
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 12, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you do not agree
with the Plan's denial. The Plan denied your request. The Plan says the ambulance benefit is a transportation
benefit. If there is no transport, then there is no Medicare-covered service.
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 12, 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 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve the service.
Therefore, we decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a urology office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a urology office visit. You say that you would feel more comfortable having a follow-up visit with the same provider that inserted your stent. The Plan denied your request. The Plan says this is available 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 urology office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas neoGen-series therapy and Vasopneumatic device therapy provided to the enrollee on October 16, 2020.
You asked the Plan to pay for the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of these services has not been demonstrated in the literature.
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 pay for the therapy. 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 literature does not support the use of electrostimulation/electromagnetic stimulation alone for neuropathies or peripheral neuropathies caused by systemic diseases.
The use is considered experimental/investigational. Regarding the subcutaneous injection of the Food and Drug Administration (FDA) Nutri-Pharmaceutical blend, the clinical vale and effectiveness in the setting of chronic pain has not been demonstrated in the peer-reviewed literature. The review has determined that the services at issue in this case are not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapy have not been met. Therefore, we decided that the Plan does not have to pay for Sanexas neoGen-series therapy and Vasopneumatic device therapy provided to the enrollee on October 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the required criteria has not been met.

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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has diabetes but is insulin independent. The elements of the coverage rule are not satisfied. 

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364) provided June 29, 2021.
You asked the Plan to pay for the cone beam CT scan. You say that the services provided were for an emergency. The Plan denied your request. The Plan says this service is 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 cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364) provided June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes to be provided by an out-of-network
provider.

You asked the Plan to pre-approve diabetic shoes from an out-of-network provider. You say that you need the
shoes right away. The Plan denied your request. The Plan says there is no medical reason as to why you cannot
get the diabetic shoes from an in-network provider.

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 at issue in this appeal. We found no exception that would require the Plan
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve diabetic shoes to
be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an office visit and injection provided on May 21, 2021.
You asked the Plan to pay for office visit and injection. You say that you were seen as an emergency after moving to North Carolina. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the service was not an urgent care visit.
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. Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit medical records or any document attempts to obtain medical records for this visit. You say that you were seen by this provider on an emergency basis while you were outside of the Plan's service area. Without medical records, we cannot determine whether the services provided to you were emergent or urgent in nature. Therefore, the Plan has not shown that its decision to deny payment for these services is correct according to Medicare rules and your contract with the Plan, or medically justified. Therefore, we decided that the Plan has to pay for an office visit and injection provided on May 21, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a folding power scooter. 
 
You asked the Plan to pre-approve a folding power scooter. You say that this item is necessary to fit into your 
vehicle in case you need it for medical appointments. The Plan denied your request. The Plan says you have an 
item that performs a duplicate purpose to the requested item. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a folding power scooter.
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 
April 20, 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 out of network physician services provided to the 
enrollee on April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gene analysis testing for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available documentation does not demonstrate that the requested genetic testing will directly impact the management and treatment of the enrollee, and/or the outcome in this case. Additionally, it has not been shown that the number of genes in the requested genetic testing is medically reasonable and necessary to obtain the necessary information for therapeutic decision making. 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve gene analysis testing for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services received on 
June 7, 2021, and June 9, 2021. 
 
You asked the Plan to waive the copayment for the services. You say that you shouldn't have to pay these 
copayments. The Plan denied your request. The Plan says the copayments were processed 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 $200 
copayment for outpatient hospital services.  
 
You have been asked to pay $110.51 for each of the dates of service. In this case, the allowed amount for these 
services was $110.51, less than the usual copayment. The services fall within the outpatient hospital 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 outpatient hospital services 
received on June 7, 2021, and June 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous implant for the enrollee.
You asked the Plan to pre-approve the implant. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure has not been shown to be helpful.
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 implant. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found these implants are experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the implant have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous implant for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services (A4550, S0028, A9150, & A4930) provided April 27, 2021.
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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. We find that CPT code A4550, S0028, A9150, & A4930 is not supported in the medical record. Specifically, the claim was not billed following Outpatient Prospective Payment System (OPPS) rules. Payment was rendered to the facility. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient services (A4550, S0028, A9150, & A4930) provided April 27, 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) and supplies.
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary. The Plan denied your request. The Plan says that medical records document that you inject insulin twice a day and do not use an insulin pump.
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 you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM) and supplies.