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

We decided that the Plan does not have to pay for the core buildup, including any pins when required provided 
on October 6, 2020. 
 
You asked the Plan to pay for the core buildup. You say that you would like the core buildup to be covered 
because it was an inherent part of the crown. The Plan denied your request. The Plan says this service is not 
covered by your dental plan. The Plan also says that core buildup is not considered a restorative service. 
 
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 core 
buildup, including any pins when required provided on October 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an air purifier. 
 
You asked the Plan to pre-approve air purifier. You say that you have trouble breathing and suffer from 
allergies, colds, and nasal congestion. The Plan denied your request. The Plan says the denial of authorization 
for this item is correct, because this item is not medically necessary for you. 
 
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 an air purifier.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia (01830).

You asked the Plan to pay for anesthesia. You say that this is payable as billed. The Plan denied your request.
The Plan says this code is not supported in the records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 01830 is anesthesia for open or surgical
arthroscopic/endoscopic procedures on distal radius, distal ulna, wrist, or hand joints; not otherwise specified.

We find that CPT code 01830 is not supported in the medical record. Specifically, documentation of anesthesia
administration is absent from the submitted medical records. Based on this information, we decided that
Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have
to pay for anesthesia (01830).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for external mobile cardiovascular telemetry.

You asked the Plan to pay for external mobile cardiovascular telemetry (93229). You say that the Plan should pay this claim. The Plan denied your request. The Plan says they need the primary insurance Evidence of Benefit to see what was denied or paid on this claim.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan reached out to the primary payer for the Explanation of Benefit. As the secondary insurer, the Plan cannot be held responsible for external mobile cardiovascular telemetry (93229) until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for external mobile cardiovascular telemetry.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the coinsurance for therapeutic continuous glucose monitor (CGM) supply allowances.

You asked the Plan to waive the coinsurance for continuous glucose monitor supplies. You say that these claims should be corrected to reduce your balance to only the $100 deductible amount. The Plan denied your request. The Plan says that the coinsurance amounts you are being charged are correct.

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 enrollees must pay $0 copayment for in-network therapeutic continuous glucose monitor supply allowances, after the deductible is applied. The full $100 deductible did apply to the claim, however; per your appeal request you are not disputing the application of the deductible.

The Plan says you must pay $709.12, which is 20% coinsurance for continuous glucose monitor supplies. Based on the Plan contract, however, you cannot be asked to pay more than $0 copayment - after the deductible is applied - for continuous glucose monitor supplies. Therefore, we decided that the Plan has to waive the coinsurance for therapeutic continuous glucose monitor (CGM) supply allowances.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eyewear rendered on October 30, 2020.

You asked the Plan to pay for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the claim was processed correctly.

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 up to $200 towards the purchase of frames. 

We looked at the file and the Plan's rules. The file shows that you purchased routine frames for a total of $851 on October 30, 2020. The Plan applied the full $200 benefit for these services, leaving you with a balance of $651. Further payment is not covered by your supplemental benefit or your medical benefit. Therefore, we decided that the Plan does not have to pay for the routine eyewear rendered on October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial and subsequent hospital care rendered from March 3, 2020 to March 14, 2020.

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 diagnosis is not supported.

The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. 

We looked at the file and Medicare rules. The file shows that the claim was billed with a secondary only diagnosis code. There is no valid primary diagnosis code billed on the claim. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the initial and subsequent hospital care rendered from March 3, 2020 to March 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on 
October 19, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were not advised 
that your insurance was changed. The Plan denied your request. The Plan says your benefits for these services 
had been satisfied and the frequency limitations had been exceeded. The Plan also says that you did not contact 
the Plan prior to the date of service to verify 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, periodic oral evaluation and 
prophylaxis are each limited to one procedure per calendar year. The record shows that you received a periodic 
oral evaluation and prophylaxis on January 20, 2020, and your periodic oral evaluation and prophylaxis 
benefits had been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral 
evaluation and prophylaxis provided on October 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cataract surgeries provided on October 29, 2020, and November 17, 2020.

You asked the Plan to waive the copayments for cataract surgeries. You say that you disagree with the charges. 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 $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 

You received cataract surgeries on October 29, 2020, and November 17, 2020. Therefore, you are responsible to pay a $350 copayment per each surgery. The total amount you owe is: $700. 

You have been asked to pay the total copayment amount of $700 for cataract surgeries. Cataract surgeries fall within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 cataract surgeries provided on October 29, 2020, and November 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fosaprepitant dimeglumine.
You asked the Plan to pre-approve the fosaprepitant dimeglumine. You say that you would like reconsideration
because this drug is medically necessary. The Plan denied your request. The Plan says fosaprepitant
dimeglumine requires patient has a moderate or high risk of nausea or vomiting.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 fosaprepitant dimeglumine. Our
reviewer says that fosaprepitant dimeglumine is not FDA-approved your diagnosis. Our physician reviewer
found its use is not supported by one of the major drug compendia or by clinical research that appears in a
CMS-approved medical journal.
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 fosaprepitant dimeglumine have not been met. Therefore, we decided that
the Plan does not have to pre-approve fosaprepitant dimeglumine.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 9, 2020, by an out-of-
network (OON) provider.
You asked the Plan to pay for the urinalysis. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says these services were not urgent, emergent or approved
in advance.
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 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 the medical services provided on October 9, 2020,
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nuclear stress test.

You asked the Plan to waive the copayment for these services. You say that the copayment is a financial hardship. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for each Medicare-covered advanced radiology service.

Review of the file shows that you received a nuclear stress test. You have been asked to pay a $150 copayment for these services. These services fall within the Medicare-covered advanced radiology service 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 nuclear stress test.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for topical aminolevulinic acid HCL (a Medicare Part B prescription drug).

You asked the Plan to waive the coinsurance for Part B drug. You say that the Plan told you that this would be covered completely. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.

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 20% coinsurance for Part B drug. The allowed amount of this drug is $306, resulting in a coinsurance responsibility of $61.20.

You have been asked to pay 20% coinsurance for Part B drug. Part B drug falls within the Medicare Part B Prescription Drugs 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 coinsurance for topical aminolevulinic acid HCL (a Medicare Part B prescription drug).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (76770, 81003, 52000) provided on August 26, 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 there were network providers available that could provide 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for lab services (76770, 81003, 52000) provided on August 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery for Vertiflex superion (Spinal Distraction
Devices) for the enrollee.
You asked the Plan to pre-approve surgery for Vertiflex superion (Spinal Distraction Devices). You say that
this surgery is medically necessary. The Plan denied your request. The Plan says Vertiflex superion (Spinal
Distraction Devices) is not covered by Medicare as it is considered experimental.
The Plan must follow Medicare rules. Medicare does not pay for experimental services or devices.
The Vertiflex superion (Spinal Distraction Devices) is not currently covered by Medicare as either initial
treatment or for replacement of treatment as it is considered experimental. Therefore, we decided that the Plan
does not have to pre-approve surgery for Vertiflex superion (Spinal Distraction Devices) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided 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 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 the acupuncture services provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vedolizumab (Entyvio).

You asked the Plan to pre-approve Entyvio. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 Entyvio. Our reviewer says that Entyvio is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the medical records provided the enrollee has not tried and failed the required drug, Stelara. Our reviewer also found that there is no indication that the Plan's required drug would likely be less effective and/or likely have adverse effects for the 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 Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Vedolizumab (Entyvio).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy provided by an opted-out provider.

You asked the Plan to pay for medical nutrition therapy. You say that the enrollee did not receive any documentation stating that certain providers would not be paid. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider had opted out of Medicare and is not payable.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy provided by an opted-out provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from July 27, 2020, to August 26, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require daily skilled therapy services on an inpatient basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from July 27, 2020, to August 26, 2020.