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

We decided that the Plan does not have to pay for the panoramic x-ray and problem focused limited oral
evaluation provided on February 5, 2020.
You asked the Plan to pay for the panoramic x-ray and problem focused limited oral evaluation. You say that
you gave the bitewing x-ray to the provider ahead of time. You also say that this provider should not file a bill
for the x-ray because they already had an x-ray. The Plan denied your request. The Plan says these services are
not covered 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
panoramic x-ray and problem focused limited oral evaluation provided on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper GI endoscopy provided on November 25, 2019.
You asked the Plan to waive the copayment for the upper GI endoscopy. You say that the endoscopy and the colonoscopy are supposed to be fully covered by any kind of Medicare Advantage Plan. 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 $295 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $295 copayment for the upper GI endoscopy. The upper GI endoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows a diagnosis of epigastric pain which makes the upper GI endoscopy diagnostic in nature.
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 upper GI endoscopy provided on November 25, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychotherapy visit, 60 minutes (90837) provided on
January 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy visit, 60 minutes provided by an OON provider. You say that
you were not advised that your provider was no longer in-network. The Plan denied your request. The Plan
says prior authorization was not requested or received for the services, therefore coverage criteria has not been
met.
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 a psychotherapy visit, 60 minutes (90837)
provided on January 13, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pleural drainage (32557) provided on November 13, 2019 through November 14, 2019.
You asked the Plan to pay for the pleural drainage. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
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 32557 is pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance. We asked our coder 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 pleural drainage. Our reviewer says that CPT code 32557 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of Pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance as there is no documentation to support imaging guidance, therefore it is inappropriate to use CPT code 32557 to describe the services performed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pleural drainage have not been met. Therefore, we decided that the Plan does not have to pay for pleural drainage (32557) provided on November 13, 2019 through November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provide on October 17, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for nurse practitioner services provide on October 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the services rendered to you on November 27, 2019.
You asked the Plan to waive the cost sharing for these services. You say that you reached your maximum out-of-pocket and were overcharged. The Plan denied your request. The Plan says the cost sharing 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 $20 copayment for services obtained from a specialist and a 20% coinsurance for each Medicare-covered chemotherapy drug and the administration of that drug.
Review of the file shows that you received specialist services on November 27, 2019. You have been asked to pay a $20 copayment for these services. These services fall within the services obtained from a specialist 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.
The file shows that you received Part B chemotherapy drugs on November 27, 2019. You have been asked to pay a 20% coinsurance for these services, for a total of $1,979.95. These services fall within the Medicare-covered chemotherapy drug 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.
The file shows that you received chemotherapy administration services on November 27, 2019. You have been asked to pay a 20% coinsurance for these services, for a total of $40.44. These services fall within the Medicare-covered chemotherapy drug administration 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.
The file shows that you had not met your maximum out-of-pocket amount on the date the claims for these services were processed. Therefore, we decided that the Plan does not have to waive the cost sharing for the services rendered to you on November 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cyclobenzaprine tablets.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 cyclobenzaprine tablets.
Benefits for self-administered drugs 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (EKG) provided on December 29, 2017.
You asked the Plan to pay for EKG. You say that this claim was submitted within the timely filing limit. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this claim was not submitted within the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for EKG was not filed until October 22, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for an electrocardiogram (EKG) provided on December 29, 2017.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on November 12, 2019.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says nonemergent,
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 psychotherapy services provided on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiogram provided on November 18, 2019.
You asked the Plan to waive the copayment for the echocardiogram. You say that you paid your $30 copayment for your cardiology appointment. 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 $100 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility. You have been asked to pay a $100 copayment for the echocardiogram. The echocardiogram falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows that the echocardiogram was billed separately from the office visit.
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 echocardiogram provided on November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro 2 motion orthotic device for the enrollee.
You asked the Plan to pre-approve a MyoPro 2 motion orthotic device. The Plan denied your request. The Plan says that literature supports that further studies are needed to confirm the clinical utility of this device.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a MyoPro 2 motion orthotic device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. The MyoPro Orthosis is not the most appropriate available supply or level of service for the patient in question considering potential benefits to the patient. It is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this patient, improve his hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase the patient's participation in bimanual activities. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of this item. 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 MyoPro 2 motion orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro 2 motion orthotic device for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computerized dynamic posturography.
You asked the Plan to pre-approve these services. You say that your physical therapist stated you need the testing to determine balance issues. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found a physician assessment dated April 15, 2020 states you have dizziness, an inner ear disorder (labyrinthitis), and hearing loss. The physician states that the stroke is likely the cause of your balance systems, not the ears. The requested computerized dynamic posturography does not have sufficient clinical value for patients with balance disorders. The services are therefore 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 pre-approve computerized dynamic posturography.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames, Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens, scratch resistant coating and miscellaneous vision service provided on January 10, 2020.
You asked the Plan to pay for these services. You say that you thought this was included in your benefit. The Plan denied your request. The Plan says that you received non-covered services.
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 one pair of eyeglass frames every year and that the eyewear benefit does not include lens options, such as tints, progressives, transition lenses, polish, and insurance. We looked at the file and the Plan's rules. The file indicates the plan has already covered one pair of eyeglass frames and you are asking for payment of lens options. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the frames, Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens, scratch resistant coating and miscellaneous vision service provided on January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the primary care physician (PCP) services rendered on December 10, 2019.
You asked the Plan to waive the copayment for these services. You say that you were told by the provider that there would be no copayment. 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 $20 copayment for each primary care doctor visit for Medicare-covered benefits.
Review of the file shows that you received PCP services on December 10, 2019. You have been asked to pay a $20 copayment for these services. These services fall within the primary care doctor visit for Medicare-covered benefits 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. The Plan cannot be held responsible for possible misinformation regarding your coverage given by a provider. Therefore, we decided that the Plan does not have to waive the copayment for the primary care physician (PCP) services rendered on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on December 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network.
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 physician services provided on December 16, 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 a combination skin protection and seat cushion (E2608) and a positioning back cushion (E2620).
You asked the Plan to pre-approve a combination skin protection and seat cushion and a positioning back cushion. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that you have problems with posture. The Plan follows Medicare rules. Medicare rules say that combination skin protection and seat cushions and positioning back cushions are only covered for diagnoses listed in the policy article. 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 combination skin protection and seat cushion and a positioning back cushion. Our reviewer says that the requested items are not medically necessary at this time. Our physician reviewer found you do not have a current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface as reflected in a required diagnosis code. You do not have absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift as reflected in a required diagnosis code. 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 combination skin protection and seat cushion and a positioning back cushion have not been met. Therefore, we decided that the Plan does not have to pre-approve a combination skin protection and seat cushion (E2608) and a positioning back cushion (E2620).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive ultrasound bone stimulator.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a second radiography obtained prior to starting treatment.
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 stimulator. Our reviewer says that the requested device is not medically reasonable or necessary. Our physician reviewer found the criteria is not met, as toe fractures are not long bone fractures. Not enough time has passed since the surgery to establish a non-union. Nine months is needed after the surgery. 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 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-invasive ultrasound bone stimulator.