Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the cost sharing for services you had with an out-of-network otolaryngologist on June 30, 2021.  You asked the Plan to reduce the cost sharing for the out-of-network otolaryngology services. You say that the Plan authorized you to go to this out-of-network doctor between July 27, 2021, and September 27, 2021.  You would like claims prior to July 27m 2021 treated as in-network in terms of cost sharing.  You stated that your in-network doctor needed to submit paperwork to get this approved, and this did not occur until after some of the services with this out-of-network doctor. The Plan denied your request. The Plan says you did not have authorization for these services to be considered in-network.  You did not have authorization until July 27, 2021, so these services processed appropriately with the out-of-network cost sharing.  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 50% coinsurance for out-of-network specialist services.   You have been asked to pay 50% coinsurance for the out-of-network otolaryngology services. These services occurred with an out-of-network provider before you had gotten authorization.  We cannot require the Plan to reduce your cost sharing to the in-network level if you did not have authorization from the Plan. 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 reduce the cost sharing for services you had with an out-of-network otolaryngologist on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the neuropathy support supplement purchased on May 14, 2021.  You asked the Plan to pay for the neuropathy support supplement. You say that you ordered the supplements and the pain decreased by over 90% without prescribed medication. You say that this works for you and the claim should be reconsidered for reimbursement. The Plan denied your request. The Plan says the neuropathy supplement, Alpha Lipoic Acid, is not listed as a covered item.  You have a $550 Pick Your Perks Benefit that is available for eligible over-the-counter items. The neuropathy support supplement is not listed as an eligible item. Therefore, we decided that the Plan does not have to pay for the neuropathy support supplement purchased on May 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial hospital care (99223) provided on April 1, 2021.  You asked the Plan to pay for the initial hospital care. 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.  Medicare guidelines say that ICD-10-CM has a coding convention for severe sepsis that requires a minimum of 2 codes. A code from subcategory R65.2 can never be assigned as a principal diagnosis. In this case, R65.20 cannot be used as the primary or first-listed diagnosis code on the claim. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99223) provided on April 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for services provided out of network on August 2, 2021.  You asked the Plan to pay for out of network services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you 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 it covers 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. The Plan did not pre-approve the service at issue. Therefore, the Plan does not have to pay for services provided on August 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint injection services.  You asked the Plan to pre-approve facet joint injection services. You say that these services are medically necessary for managing the enrollee's condition. The Plan denied your request. The Plan says the coverage criteria have not been met.  The Plan follows Medicare rules. Medicare rules say that facet joint injection services are subject to the criteria listed 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 facet joint injection services. Our reviewer says that the requested injection services are not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 48-year-old male with chronic low back/lumbar pain with lumbar radiculopathy to both lower extremities and right leg/knee numbness.  According to the telemedicine visit, November 1, 2021, the enrollee's back pain is due to failed back syndrome post spinal cord stimulator (2016), degenerative disc disease, bilateral facetogenic pain, radicular pain bilaterally, bilateral sacroiliac joint dysfunction, bilateral piriformis pain, and myofascial pain   He currently takes Gabapentin and Cyclobenzaprine for pain relief.  The provider is requesting unilateral L2, L3, L4, and L5 medial branch blocks (x2 with return to clinic for lumbar L2, L3, L4, and L5 medial branch nerve radiofrequency ablation.  In this case, the enrollee has low back pain with associated radiculopathy. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injection services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for podiatry services provided on July 15, 2021.  You asked the Plan to waive the copayment for podiatry services. You say that you disagree with the charges because you were told that you would not owe a copayment for routine podiatry services. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for podiatry services.   The medical records show that you received podiatry services on July 15, 2021, that went beyond routine services. Therefore, you are responsible to pay the $50 copayment.   You have been asked to pay a $50 copayment for podiatry services. Podiatry services fall within the podiatry 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 podiatry services provided on July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for prophylaxis (D1110), a periodic oral evaluation (D0120), and a maxillary partial denture (D5211) provided by an out-of-network provider on April 27, 2021.  You asked the Plan to pay for prophylaxis, a periodic oral evaluation, and a maxillary partial denture. You say that you have been going to this provider for more than five years. You say that you thought this dentist was in-network. The Plan denied your request. The Plan says the member's plan does not cover out-of-network provider services.  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 because this provider is out-of-network.   Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110), a periodic oral evaluation (D0120), and a maxillary partial denture (D5211) provided by an out-of-network provider on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a continuous glucose monitor provided to the enrollee on April 2, 2021.  You asked the Plan to pay for the monitor. You say that ] The Plan denied your request. The Plan says   The Plan must follow Medicare rules. Medicare rules say that DME supplies must be provided with a proof of delivery, and a valid standard written order.  The required documentation pertaining to the proof of delivery of these supplies was not provided. The proof of delivery does not appear to match the actual items supplied. Additionally, there does not appear to be a valid order for these supplies, as the ordering provider denies ordering the supplies. 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 pay for a continuous glucose monitor provided to the enrollee on April 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Optimizer Smart Implantable Pulse Generator.  You asked the Plan to pre-approve an Optimizer Smart Implantable Pulse Generator. You say that the requested Optimizer Smart Implantable Pulse Generator is medically necessary. The Plan denied your request. The Plan says the requested Optimizer Smart Implantable Pulse Generator 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 an Optimizer Smart Implantable Pulse Generator. Our reviewer says that the requested Optimizer Smart Implantable Pulse Generator is not medically necessary. Our physician reviewer found review of the current medical literature pertaining to the cardiac contractility modulation (CCM) system confirms multiple observational studies suggesting clinical benefit from CCM.  Several randomized clinical trials of CCM versus control have also been reported, along with meta-analysis pooling the data from multiple studies, with CCM providing meaningful improvement in quality-of-life scores and objective functional capacity. While the clinical studies led to FDA approval in 2019, CCM remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, the CCM system is not medically necessary for this enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Optimizer Smart Implantable Pulse Generator have not been met. Therefore, we decided that the Plan does not have to pre-approve an Optimizer Smart Implantable Pulse Generator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for oxygen equipment purchased on June 15, 2021.  You asked the Plan to pay for the purchase. You say that you have multiple medical appointments hours away from your home oxygen. The Plan denied your request. The Plan says Medicare only covers rental of oxygen equipment, not purchases.  The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is statutorily non-covered.  We looked at this physician's review, the file, and Medicare rules. The denied item was purchased. Medicare only covers oxygen equipment that was rented. Based on this information, we decided that Medicare rules for coverage of the purchase have not been met. Therefore, we decided that the Plan does not have to pay for oxygen equipment purchased on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office visit (99204) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve an office visit. You say that you would prefer to see this OON provider. The Plan denied your request. The Plan says there are multiple in-network providers available to provide the care you need.  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 an office visit (99204) 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 waive the copayment for the visit you had with an otolaryngologist on June 15, 2021.  You asked the Plan to waive the copayment for the otolaryngology visit. You say that you received a routine eye exam, so there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $25 copayment for visits with a specialist.   You have been asked to pay a $25 copayment for the otolaryngology visit. We looked at the medical records from this visit.  The records show that this was not a routine eye exam.  The records show that this otolaryngology visit was for the purposes of evaluating your hearing loss. 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 visit you had with an otolaryngologist on June 15, 2021.
Appeal type: Surgery
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 the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.  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.    Our physician reviewer found the enrollee's medical conditions are stable and there are no complex nursing or rehabilitation needs. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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 waive the copayment for the transthoracic echocardiography (TTE) you received on October 27, 2020.  You asked the Plan to waive the copayment for the TTE. You say that these services were medically necessary and they should be covered. The Plan denied your request. The Plan says this service was not denied. Rather, you were charged the appropriate cost sharing for this service.  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 $100 copayment for diagnostic procedures and tests.      You have been asked to pay a $100 copayment for the TTE. The TTE falls within the diagnostic procedures and tests 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 the transthoracic echocardiography (TTE) you received on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the destruction of benign lesions (17110) and the destruction of premalignant lesions (17000) rendered by the out-of-network (OON) provider on July 12, 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 destruction of benign lesions (17110) and the destruction of premalignant lesions (17000) rendered by the out-of-network (OON) provider on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for telehealth visits with a specialist provided on March 16, 2021, and June 15, 2021.  You asked the Plan to waive the copayments for telehealth visits with a specialist. You say that you thought that you did not owe copayments for telehealth visits. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for specialist visits, including telehealth visits.   You received telehealth visits with a specialist on March 16, 2021, and June 15, 2021. Therefore, you are responsible to pay a $45 copayment per each visit. The total amount you owe is: $90.  You have been asked to pay the total copayment amount of $90 for telehealth visits with a specialist. Telehealth visits with a specialist 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 telehealth visits with a specialist provided on March 16, 2021, and June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye refraction provided by an out-of-network provider on December 14, 2020.  You asked the Plan to pay for eye refraction. You say that you are requesting reimbursement of this charge because you were not able to see the provider without paying it. The Plan denied your request. The Plan says the denial of payment for this service is correct, because routine vision services must be received from a provider in the Plan's vision vendor network and eye refractions are not covered outside of the annual supplemental routine eye exam.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to 1 time per year when obtained from a provider in the Plan's routine vision network.  We looked at the file and the Plan's rules. This provider is outside of the Plan's routine vision network; therefore, routine vision services are not covered when received from this provider. Based on this information, we decided that the Plan's rules for coverage of eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction provided by an out-of-network provider on December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic counseling services (96040) provided on March 10, 2021.  You asked the Plan to pay for code 96040. 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.  We looked at the file and Medicare rules. Code 96040 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the genetic counseling services (96040) provided on March 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for an ankle control orthosis (L4350) provided on May 24, 2021.  You asked the Plan to pay for an ankle control orthosis. You say that there is a prescription and proof of delivery for this item. The Plan denied your request. The Plan says there are no records to support this item.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.     The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for an ankle control orthosis (L4350) provided on May 24, 2021.