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

We decided that the Plan does not have to pay for prophylaxis - adult (D1110) and periodic oral evaluation - established patient (D0120) provided on December 12, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that the wording is exactly the same for in-network, and out-of-network coverage, and that there is no indication of any restrictions limiting out-of-network coverage to any "allowed amounts". The Plan denied your request. The Plan says the services are covered benefits and you are responsible for the cost-share.
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. For code D1110, the provider billed the plan $98.00. The allowed amount for service is $41.00, and the plan paid $41.00. You are responsible for all fees in excess of the allowed amount, $57.00 ($98 - $41). For code D0120, the provider billed the plan $50.00. The allowed amount for service is $19.00, and the plan paid $19.00. You are responsible for all fees in excess of the allowed amount, $31.00 ($50 - $19). You are responsible for all fees in excess of the allowed amount, $88.00 ($148 - $60). The $88.00 which was assessed your responsibility is correct. Therefore, we decided that the Plan does not have to pay for prophylaxis - adult (D1110) and periodic oral evaluation - established patient (D0120) provided on December 12, 2019 by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency routine transportation (A0120).
You asked the Plan to pre-approve the routine transportation. You say that you recently had a stroke and is unable to drive. You have multiple follow up appointments and has no way to reach the appointments. The Plan denied your request. The Plan says this is not covered under the plan benefits.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of the routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergency routine transportation (A0120)..
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided by an out of network (OON) provider.
You asked the Plan to pay for wound care. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the provider had ample enough time to request an 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 wound care provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto 97mg-103mg tablets.
You asked the Plan to pre-approve Entresto 97mg-103mg tablets. You say that the requested medication is
necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not
include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been
met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Entresto 97mg-103mg
tablets.
Benefits for Entresto 97mg-103mg tablets 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the arch supports purchased on October 1, 2019 from a non-Medicare provider.You asked the Plan to pay for the services. You say that you had been seeing your regular foot doctor but had not been getting a lot of relief. You state you did not get a referral as you did not know one would have been needed.The Plan denied your request. The Plan says they cannot make payment for Medicare covered services to a provider who does not accept Medicare payment.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.You purchased services on October 1, 2019 from a provider that does not participate with Medicare. The Plan cannot make payment for Medicare covered services to a provider who does not accept Medicare payment.Therefore, we decided that the Plan does not have to pay for the arch supports purchased on October 1, 2019 from a non-Medicare provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an
out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says medically necessary care is available within the plan's network of contracted
neurological PT providers.
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 referral to an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for rental of a portable oxygen concentrator purchased from an out-of-network provider while on a cruise ship.
You asked the Plan to pay for the DME. You say that you are requesting reimbursement of services rendered.
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 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 rental of a portable oxygen concentrator purchased
from an out-of-network provider while on a cruise ship.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the medical services you received.
You asked the Plan to pay for the medical services. You say that the doctor required an initial physical as your new doctor. The Plan denied your request. The Plan says that the service is only covered once per year.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You received the medical services at issue by a contract provider. The file does not show that the Plan provided notice that the medical services would not be covered. Under Medicare rules, this means the services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the medical services you received.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLinzess capsules.You asked the Plan to pre-approvethe Linzess capsules. The Plan denied your request. The Plan says this medication does not fall under 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-approveLinzess capsules.Benefits for the Linzess capsulesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Supplemental Benefit
Decision: Unfavorable

e decided that the Plan does not have to pay forthe hearing aids purchased on March 15, 2019.You asked the Plan to pay forthe hearing aids. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.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. We looked at the file, and the Plan's rules. Review of the file show that you purchased the hearing aids on March 15, 2019. The Plan paid $100. Your EOC states, enrollees have a $100 allowance per hearing aid device per ear every three (3) years. You pay any amount over this plan allowed amount.Therefore, we decided that the Plan does not have to pay forthe hearing aids purchased on March 15, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9366)
You asked the Plan to pay for home infusion therapy. You say that this should be paid as an in-network service. The Plan denied your request. The Plan says this code is not valid.
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 code S9366 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9366)
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve myocardial perfusion imaging (78451).You asked the Plan to pre-approve myocardial perfusion imaging. You say that the services are necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that myocardial perfusion studies performed based on the presence of risk factors in the absence of cardiac symptoms, cardiac abnormalities on physical examination, or abnormalities on cardiac testing will be considered screening and denied as not covered by Medicare.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 myocardial perfusion imaging. Our reviewer says that the services are medically necessary. Our physician reviewer found medical record documentation provided confirms that the enrollee has had recent exertional chest discomfort consistent with angina. The requested Myocardial Perfusion imaging is 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 myocardial perfusion imaging have been met.Therefore, we decided that the Plan has to pre-approve myocardial perfusion imaging (78451).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 a domiciliary, rest home visit provided.
You asked the Plan to pay for the domiciliary, rest home visit. 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 a domiciliary, rest home visit provided.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 25, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice on September 20, 2019. The Plan says, per Medicare guidelines, the provider needs to bill Original Medicare for the services provided on September 25, 2019.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on September 20, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical mask.You asked the Plan to pre-approve the mask. You say that you need this as soon as possible, as you could get infected by Covid-19.The Plan denied your request. The Plan says this is denied, as it is a non-reusable disposable item.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 a surgical mask.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for CPT code G0482 provided on August 20, 2019.
You asked the Plan to pay for CPT code G0482. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the medical records do not support CPT code G0482.
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 G0482 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. We find that CPT code G0482 is supported in the medical record. Specifically, the record does contain evidence that definitive testing on 15-21 drug classes was performed. Based on this information, we decided that Medicare rules for coverage of CPT code G0482 have been met. Therefore, we decided that the Plan has to pay for CPT code G0482 provided on August 20, 2019.
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 the home infusion therapy (S9328) provided and reported with HCPCS code S9328.
You asked the Plan to pay for HCPCS code S9328. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that HCPCS code S9328 has a status code of I, which is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules say that HCPCS/CPT codes with a status indicator of I are not recognized by Medicare and will not be paid. Medicare uses another code for reporting of, and payment for, these services. We find that CPT code S9328 is not supported in the medical record. Specifically, S9328 has a status indicator of I and will not be paid by Medicare. This service should be reported with a code that is recognized by Medicare. 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 home infusion therapy (S9328) provided and reported with HCPCS code S9328.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (E2611, E2201, E0973, E0951, and E0961) provided on June 5, 2019.You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the documentation provided did not include a valid physician order.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 the physician order documentation for the items at issue in this appeal. The record does not contain a valid physician order for the supplies provided in this case.Therefore, we decided that the Plan does not have to pay for the durable medical equipment (E2611, E2201, E0973, E0951, and E0961) provided on June 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from December 21, 2019 through December 30, 2019 provided by an in-network provider.You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care from December 21, 2019 through December 30, 2019 provided by an in--network provider. You are asked to pay a $250 copayment per day, days 1-5 for in-network inpatient hospital care. 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 inpatient hospital care from December 21, 2019 through December 30, 2019 provided by an in-network provider.