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

We decided that the Plan does not have to pay for physician services provided to the enrollee on December 10,
2020.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says due to the enrollee's hospice election at the time of service, this claim should be
submitted to Original Medicare first for review.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for physician services provided to the enrollee on December 10,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to waive the $75 cost share physician services provided on May 12, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was applied based on the services provided and the Plan contract agreement.
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 there is a cost share for each service provided. 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 $75 cost share physician services provided on May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on July 8, 2021.
You asked the Plan to pay for the eye refraction. You say that that you needed to see an eye specialist for your medical condition. The Plan denied your request. The Plan says you have exhausted the benefit.
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.
We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-covered eye condition and not a routine eye exam. The file shows that part of this exam was for a refraction. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on July 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you medically need orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this has always been covered for your foot pain. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture, one or more needles, without electrical stimulation, initial 15 minutes (97810) acupuncture, one or more needles, without electrical stimulation, each additional 15 minutes (97811) infrared light therapy (97026) provided February 8, 2021.
You asked the Plan to pay for the acupuncture and infrared therapies. You say that according to the enrollee's benefit verification, this is a covered benefit under the health Plan. Please review the enclosed documentation and allow for coverage as the services rendered were medically necessary. The Plan denied your request. The Plan says the Plan does not cover this expense and does not meet Medicare criteria.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the records show that the treatment was for right shoulder and neck pain. Infrared therapy is considered not reasonable and necessary by Medicare and is excluded from coverage. Therefore, we decided that the Plan does not have to pay for acupuncture, one or more needles, without electrical stimulation, initial 15 minutes (97810) acupuncture, one or more needles, without electrical stimulation, each additional 15 minutes (97811) infrared light therapy (97026) provided February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture, one or more needles, without electrical stimulation, initial 15 minutes (97810) acupuncture, one or more needles, without electrical stimulation, each additional 15 minutes (97811) infrared light therapy (97026) provided February 17, 2021.

You asked the Plan to pay for the acupuncture and infrared therapy services. You say that according to the enrollee's benefit verification, this is a covered benefit under the health Plan. Please review the enclosed documentation and allow for coverage as the services rendered were medically necessary The Plan denied your request. The Plan says the Plan does not cover this expense and does not meet Medicare criteria

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the records show that the treatment was for right shoulder and neck pain. Infrared therapy is considered not reasonable and necessary by Medicare and is excluded from coverage. Therefore, we decided that the Plan does not have to pay for acupuncture, one or more needles, without electrical stimulation, initial 15 minutes (97810) acupuncture, one or more needles, without electrical stimulation, each additional 15 minutes (97811) infrared light therapy (97026) provided February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) and the nasal endoscopy, diagnostic, unilateral or bilateral (31231) rendered by the out-of-network (OON) provider on February 9, 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 office visit (99213) and the nasal endoscopy, diagnostic, unilateral or bilateral (31231) rendered by the out-of-network (OON) provider on February 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
You asked the Plan to provide a therapeutic continuous glucose monitor (K0554) and supply allowance (K0553). You say that you need a CGM. The Plan denied your request. The Plan says the information does not show the enrollee is insulin dependent.
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 therapeutic continuous glucose monitor (K0554) and supply allowance (K0553) have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible applied to lab services you received on January 7, 2021.
You asked the Plan to waive the deductible applied to the lab services. You say that You did not provide an explanation with your appeal. You simply provided copies of bills you received. The Plan denied your request. The Plan says you were charged this deductible correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible which applies to lab services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to lab services. This cost sharing is a contractual obligation that had not been met at the time the lab services was received on January 7, 2021. Therefore, we decided that the Plan does not have to waive the deductible applied to lab services you received on January 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 7, 2021.
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 physician's services provided on June 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) provided June 9, 2021.
You asked the Plan to pay for the office visit. You say that as shown on the Medicare.gov website, the provider
is eligible to participate in Medicare. You request reimbursement for the visit at the out-of-network rate. The
Plan denied your request. The Plan says 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 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 outpatient office visit (99214)
provided June 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on March 30, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that you did not receive these services. 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 $225 copayment for ambulance services. 
You have been asked to pay a $225 copayment for the ambulance services. The medical records show that you were transported at the request of your doctor's office for altered mental status. The records show that you went to the wrong appointment that morning and appeared confused. Your primary care physician was contacted and advised the ambulance to transport you to the emergency room. In addition, you signed a document on the date of service acknowledging that ambulance services were provided to you. 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 ambulance services provided on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature shows that this service is considered to be experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental. More research is needed to show safety and efficacy for low back pain treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgery services rendered by the out-of-network (OON) provider on April 15, 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 outpatient surgery services rendered by the out-of-network (OON) provider on April 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested
out-of-network provider.
You asked the Plan to pre-approve physical therapy to be provided by the requested out-of-network provider. The Plan denied your request. The Plan says enrollee's care must be received within the network, and no gap issues exist.
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 services at issue in this appeal. 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 physical therapy to be provided by the requested out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87502, 87532, 87541,
87581, 87634, 87640, 87798) provided August 19, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the services.

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 codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, & 87798 are not
supported in the medical record. Specifically, the place of service listed on the claim (81, lab) does not match
the place of service detailed in the records (11, office setting). Based on this information, we decided that
Medicare rules for coverage of the lab services have not been met.

Therefore, we decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided August 19, 2020.
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 April 23, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request.
The Plan says the Medicare ambulance benefit is a transport benefit and if there no transport then there is no
coverage.

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 April 23, 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 April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the upper and lower partial denture provided on April 16, 2021 and the extraction provided on April 21, 2021.
You asked the Plan to pay for the upper and lower partial denture and extraction. You say that you were told the wrong information and these services were not covered. The Plan denied your request. The Plan says out-of-network dental services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the upper and lower partial denture provided on April 16, 2021 and the extraction provided on April 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy with Botox.
You asked the Plan to pre-approve treatment with Botox. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested treatment have 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 treatment with Botox. Our reviewer says that the requested drug is not considered medically reasonable and necessary in this case. Our physician reviewer found that, based on the medical records provided, there is no documentation that the enrollee meets coverage criteria for the requested use of Botox. The provided records do not document a diagnosis of esophageal achalasia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of treatment with Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy with Botox.