Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided October 1, 2020, to December 1, 2020.

You asked the Plan to pay for the therapeutic continuous glucose monitor. You say that this request was medically necessary. The Plan denied your request. The Plan says the criteria for the therapeutic continuous glucose monitor have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided October 1, 2020, to December 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency wheelchair transport services provided on September 28, 2020.

You asked the Plan to pay for the services. You say that the enrollee was weak and very large. You state you could not get the enrollee in and out of your vehicle. The Plan denied your request. The Plan says a wheelchair van transport is not covered by Medicare nor by the enrollee's benefits.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. 

The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for non-emergency wheelchair transport services provided on September 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81406, 81407, 81408) provided May 18, 2020.

You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation provided does not support that the services were medically necessary.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic testing (81406, 81407, 81408) provided May 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (36415, 80061, 82728, 83036, 83540, 83721, 84439, 84443, 84466, G0433, 85025, 85610, 85730) provided on October 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON laboratory services. You say that these services should be covered because you moved. The Plan denied your request. The Plan says these 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 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 laboratory services (36415, 80061, 82728, 83036, 83540, 83721, 84439, 84443, 84466, G0433, 85025, 85610, 85730) provided on October 14, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the general health panel rendered on July 7, 2020 to October 13, 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 testing is not covered.

The Plan must follow Medicare rules. The rules say that a GHP (code 80050) is not covered or paid for by Medicare.

The services at issue are a GHP billed with code 80050. Therefore, the Plan does not have to pay for the testing. Therefore, we decided that the Plan does not have to pay for the general health panel rendered on July 7, 2020 to October 13, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for a clinic visit provided on November 4, 2020.

You asked the Plan to pay for the clinic visit. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 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 a clinic visit provided on November 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the gurney van for transportation and over the counter items provided from November 3, 2020, through November 10, 2020.

You asked the Plan to reimburse you for the gurney van for transportation and over the counter items. The Plan denied your request. The Plan says the services rendered and purchased were excluded from coverage in the enrollee's Evidence of Coverage.

We looked at the file, the Medicare rules and the Plan's rules. The rules say that Medicare does not pay for over the counter items. The Plan says over the counter items are excluded from coverage and the Plan does not cover the gurney van for transportation. Therefore, we decided that the Plan does not have to reimburse you for the gurney van for transportation and over the counter items from November 3, 2020, through
November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99215) provided on October 27, 2020.

You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent. There were network providers available.

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 an office visit (99215) provided on October 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110) provided on December 21, 2020.

You asked the Plan to pay for the cleaning. You say that the Plan should pay for half of this service because you have the additional optional dental benefit. The Plan denied your request. The Plan says only two cleanings are covered per year. The Plan has already paid for two cleanings for you in 2020. Therefore, payment cannot be made for a third cleaning. In addition, cleanings are covered under the mandatory supplemental dental benefit. No additional cleanings are covered under the optional dental benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110) provided on December 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on December 1, 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 services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing is covered when specific criteria are met.
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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has an elevated prostate specific antigen (PSA) and a biopsy on December 1, 2020 demonstrated very low risk stage T1c prostate cancer. He is being managed by active surveillance and the criteria for coverage are not met. The ConfirmMDx testing was not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing rendered on December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids.

You asked the Plan to pre-approve hearing aids. You say that you lost your hearing aid and are not
sure where it is, and you need a new hearing aid. The Plan denied your request. The Plan says the
denial of authorization for a hearing aid is correct, because you received a hearing aid on July 10,
2019 so you are not eligible for the hearing aid benefit until July 10, 2022.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid
benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this
case. The Plan pays for hearing aids only once every 3 years.

We looked at the file and the Plan's rules. You received a hearing aid on July 10, 2019, which was
less than 3 years ago. Based on this information, we decided that the Plan's rules for coverage of
hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve
hearing aids.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 11, 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 testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal, molecular genetic screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a CGM to be provided by 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 says there are in-network providers available to you that can provide the CGM you are requesting.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the apicoectomy, bone graft in conjunction with periradicular surgery, and three retrograde fillings provided on December 2, 2020.

You asked the Plan to pay for the apicoectomy, bone graft, and retrograde fillings. You say that you believe these are medical procedures and not dental procedures. The Plan denied your request. The Plan says these 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, 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 apicoectomy, bone graft in conjunction with periradicular surgery, and three retrograde fillings provided on December 2, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management, 30 minutes or less, provided on August 13, 2020.

You asked the Plan to pay for the evaluation and management service. You say that the service was medically necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management, 30 minutes or less, provided on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the periodic oral evaluation and prophylaxis provided on January 12, 2021.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that your EOC does not state that you cannot see a Medicare opt out provider. The Plan denied your request. The Plan says that the treating provider has been a Medicare opt out provider since June 7, 2017.
The Plan follows Medicare rules. Medicare rules say that the Plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. The Plan denied this request for the services being rendered by a Medicare opt out provider. The 2021 EOC states that you have a $1,500 maximum plan allowance per calendar year for non-routine dental services. The contract does not clearly state that dental services received by a Medicare opt out provider are not covered. You reasonably believed that these services would be covered up to the $1,500 annual allowance. Therefore, we decided that the Plan has to pay for the periodic oral evaluation and prophylaxis provided on January 12, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (99203) provided on October 16, 2020 to November 2, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were non-emergent. There were network providers available.

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 chiropractic services (99203) provided on October 16, 2020 to November 2, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick.
You asked the Plan to pre-approve Repatha Sureclick. You say that you would like to prescribe Repatha for the enrollee due to their intolerance to statins. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.
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 Repatha Sureclick.
Benefits for Repatha Sureclick 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 cost share for the x-ray, the cast supplies, and orthotic provided on June 4, 2020 and June 15, 2020.
You asked the Plan to waive the cost share for the x-ray, the cast supplies, and the orthotic. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an x-ray, an orthotic and cast supplies on the dates of service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan.
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 each Medicare-covered standard x-ray service, a 20% coinsurance for each Medicare-covered medical supply and a 20% coinsurance for Prosthetic Devices and Related Supplies. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an x-ray on June 4, 2020. You have been asked to pay a $31.91 copayment for the x-ray, which is less than the contracted $50 copayment amount. The x-ray falls within the Outpatient diagnostic tests benefit category. The file shows that you received an orthotic on June 4, 2020. You have been asked to pay a 20% coinsurance for the orthotic, totaling $19. The orthotic falls within the Prosthetic Devices and Related Supplies benefit category. The file shows that you received cast supplies on June 15, 2020.
You have been asked to pay a 20% coinsurance for the cast supplies, totaling $1.64. The cast supplies fall within the Outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amounts 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 for the x-ray, the cast supplies, and orthotic provided on June 4, 2020 and June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by an out of network (OON) provider on November 25, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service 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 this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by an out of network (OON) provider on November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth irrigation provided on January 11, 2021.
You asked the Plan to pay for the full mouth irrigation. You say that you believe this service should be covered. The Plan denied your request. The Plan says the periodontal maintenance was covered in full. The Plan also says that you were not charged for a full mouth irrigation on this date of service, and full mouth irrigation 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 pay for the full mouth irrigation provided on January 11, 2021.