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

We decided that the Plan does not have to pay for crown - porcelain fused to high noble metal (D2750) provided December 2, 2019.
You asked the Plan to pay for the dental services. You say that you believe that the services should be covered and you are requesting reconsideration for reimbursement of the services. The Plan denied your request. The Plan says this service is not covered under the plan 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 crown - porcelain fused to high noble metal (D2750) provided December 2, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea consultation for cataract surgery to be provided by an out of network (OON) provider.You asked the Plan to pre-approvea consultation for cataract surgery with an OON provider. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan states there are participating providers available to you that can provide the services you are requesting. The Plan says your POD.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-approvea consultation for cataract surgery 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 pay for the medical services provided to the enrollee by an out-of-network provider on September 24, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on September 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe endoscopy provided on October 8, 2019.You asked the Plan to waive the copayment forthe endoscopy. You say that should not be responsible for the copayment due to poor preparation for the colonoscopy. 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 $325 copayment for Medicare-covered outpatient surgery at an in-network ambulatory surgical center. You have been asked to pay a $325 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows youwere billed for the endoscopy and the colonoscopy was covered at no cost.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 forthe endoscopy provided on October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided to the enrollee on October 24, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided to the enrollee on October 24, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe colonoscopy provided on January 7, 2020.You asked the Plan to waive the cost share forthe colonoscopy. You say that you thought a preventive procedure was being done.The Plan denied your request. The Plan says the copayment applied 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 your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay ourshare for your covered medical services. Until you have paid the deductible amount, you must paythe full cost of your covered services.Your contract with the Plan clearly says that you must pay a $125 copayment after the deductible is met for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility.The item or service you asked the Plan to waive the cost share for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the colonoscopy was received on January 7, 2020.Therefore, $750 has been applied to meet your deductible. Since your $750 deductible was met, you have also been asked to pay a $125 copayment for the colonoscopy. The records show that a polyp was removed, which is considered a surgical procedure. 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 forthe colonoscopy provided on January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fordetermination of refractive state (92015 GY) provided January 17, 2019.You asked the Plan to pay forthe refraction services. You say that please refund the $25 that you paid to the provider. This amount should have been paid for by the plan.The Plan denied your request. The Plan says this service was billed with a GY modifier which is used to identify a non-covered service.Medicare generallydoes 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 when refractionservices is covered when provided as part of routine eye exam.We looked at the file and the Plan's rules. The provider billed this service with a GY modifier which is used to identify a non-covered service. Based on this information, we decided that thePlan's rules for coverage of the refraction services have not been met.Therefore, we decided that the Plan does not have to pay fordetermination of refractive state (92015 GY) provided January 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 21, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 17, 2019 by a non-network provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-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 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. 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 forthe medical services provided on December 17, 2019 by a non-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power scooter.You asked the Plan to pre-approvea power scooter. You say that you are in pain and has lost feeling in one of your hands.The Plan denied your request. The Plan says your functional deficit was resolved with either a manual wheelchair or a walker.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a power scooter. Our physician reviewer found that you have spinal stenosis and chronic pain. Records indicate some limited shoulder range of motion, and mild upper limb weakness. You are able to transfer from bed independently, thoughyou warrantsome assist for bathing and other activities of daily living.The records do not indicate you areincapable of safely and adequately utilizing an optimally-configured lesser device. Therefore, the requested device is not considered medically reasonable and 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 a power scooter have not been met.Therefore, we decided that the Plan does not have to pre-approvea power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 18, 2019 by an out of network (OON) provider.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says 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 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. 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 medical services provided on September 18, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are needed to reduce swelling. The Plan denied your request. The Plan says are non-covered because they do not meet the statutory definition of a dressing. The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are non-covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) provided on December 13, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code.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 shows that the Plan made several attempts to obtain documentation to validate an established relationship with the ordering physician as well as documentation of the duration of the member's condition, clinical course, prognosis, nature and extent of functional limitations, other therapeutic interventions and previously purchased DME items related to the billed items. The submitted documentation does not include this required information.Therefore, we decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) provided on December 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea core build-up (D2950).You asked the Plan to pre-approvethe core build-up. You say that the service is medically necessary.The Plan denied your request. The Plan says core build-up is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea core build-up (D2950).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alprazolam.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not covered.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve alprazolam.Benefits for these services may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on July 29, 2019.You asked the Plan to waive the copayment for the MRI. You say that you didn't need the MRI. You say that you were told that the MRI was paid for.The Plan denied your request. The Plan says the copayment 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 $275 copayment for each advanced imaging service. You have been asked to pay a $275 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for the MRI provided on July 29, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99309) provided on November 8, 2019 by physician.You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary.The Plan denied your request. The Plan says there were network providers available that could have provided the services at issue.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 has network providers available who can provide 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 the nursing facility care (99309) provided on November 8, 2019 by physician.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for crutch substitute, knee scooter (E0118).
You asked the Plan to pay for the knee scooter. You say that you need a knee scooter to get around after surgery. You won't be able to put weight on your foot for 6 months and you have not been able to locate a participating provider with this item available. The Plan denied your request. The Plan says the requested provider is not certified as a Medicare approved home equipment provider.
The Plan must follow Medicare rules. Medicare rules say that a provider must be enrolled in the Medicare program in order to receive payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee scooter have not been met. Therefore, we decided that the Plan does not have to pay for crutch substitute, knee scooter (E0118).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 1 dental extraction provided on October 31, 2019.
You asked the Plan to pay for the dental extraction. You say that you should not be responsible for the amount you are being charged. The Plan denied your request. The Plan says your benefit for dental extractions was exhausted for the 2019 calendar year.
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 1 dental extraction provided on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PAP machine, for the enrollee.
You asked the Plan to pre-approve the PAP machine. You say that the durable medical equipment is medically
necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 PAP machine have not been met. The enrollee's records show
that the enrollee is having a problem that affects their sleep. The reason this request cannot be approved is
because: the records do not show that the enrollee's current PAP machine is not working, and the supplier has
checked the device in person and found that it cannot be repaired. A PAP machine helps keep your airway open
while sleeping. Therefore, we decided that the Plan does not have to pre-approve PAP machine, for the
enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the enrollee's family was told that the transport is covered by the Plan. You stated that the enrollee cannot be safely transported by wheelchair due to the possibility of falling out and cannot sit upright for the time needed for transport. You say that the enrollee is unable to travel by car due to her medical problems and that it would be dangerous for her to travel by other means. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for the ambulance services.