Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on March
12, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you cannot pay the
copay. The Plan denied your request. The Plan says that the claim processed 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 $200
copayment for per one-way trip for emergency ambulance services and non-emergency ambulance services.
You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls
within the one-way trip for emergency ambulance services and non-emergency ambulance services 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 ambulance transport provided on March 12,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
February 24, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that this was a follow-up
visit to a procedure you had in October 2019 and you say you should not have to pay the copayment. 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 $50
copayment for each in-network Medicare-covered specialist office visit. For this date of service, you have been
asked to pay the allowed amount of the claim because this amount is less than the $50 copayment for the
specialist office visit.
You have been asked to pay a $49.93 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows
your lesion removal procedure on October 29, 2019 had a 10-day global period and the visit on February 24,
2020 is beyond the global period.
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 specialist office visit provided on February 24, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that HCPCS codes are required for all outpatient hospital services unless specifically excepted in manual instructions. We looked at the file and Medicare rules. Since self-administered drugs are not excepted in manual instructions from the requirement to report HCPCS code, such reporting is required. As such, we find that the billing rules for the payment of this claim have not been met. Therefore, we decided that the Plan does not have to pay for the services provided on February 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean excision of hyperplastic tissue (D7970), first 15 minutes of deep sedation/general anesthesia (D9222), and each subsequent 15 minute increment of deep sedation/general anesthesia (D9223).You asked the Plan to pre-approvethe excision of hyperplastic tissue and deep sedation/general anesthesia services. You say that getting these procedures done is urgent.The Plan denied your request. The Plan says these services are not covered under your benefit package.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvean excision of hyperplastic tissue (D7970), first 15 minutes of deep sedation/general anesthesia (D9222), and each subsequent 15 minute increment of deep sedation/general anesthesia (D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on February 13, 2020.
You asked the Plan to pay for the hearing aids. You say that there are no Plan hearing aids providers in your area. The Plan denied your request. The Plan says hearing aid services are not covered unless they are performed by a Plan provider.
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 when you see a Plan hearing provider. We looked at the file and the Plan's rules. The file shows that you received the hearing aids from a provider that is not a Plan hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve physician services. You say that you need this specific doctor. The Plan denied your request. The Plan says there are multiple in-network providers for these services 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 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 physician services 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 pre-approve a crown for tooth #8.
You asked the Plan to pre-approve the crown. You say that the crown has a bad smell coming from it. You also say that you have cleaned it but it still smells and is affecting your physical health. The Plan denied your request. The Plan says this service is allowed once every 60 months. The Plan also says that you had this service less than 60 months ago.
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, crowns, bridges, inlay/onlay and periodontal is limited to once per tooth every 5 years. The record shows that you received a crown on tooth #8 on August 10, 2017 and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown for tooth #8.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS)
device.
You asked the Plan to pre-approve a TENS device. You say that your provider told you a TENS unit would
help deal with your pain. The Plan denied your request. The Plan says the medical records received did not
indicate the you are enrolled in an approved clinical study.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The record does not show you are in an approved clinical study.
Based on this information, we decided that Medicare rules for coverage of a TENS device have not been met.
Therefore, we decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation
(TENS) device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve resin-based composites (D2391) for tooth #'s 21, 28, &
29.
You asked the Plan to pre-approve the resin-based composites. You say that you have 4 cavities and your
insurance only covered 1. You also say that dental health is just as important as physical health. The Plan
denied your request. The Plan says your benefit allowance has been exhausted.
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, amalgams and resin fillings are limited
to one restoration per tooth, per surface, once in 36 months. The record shows that you received resin-based
composites (D2391) on tooth #'s 28 & 29 on May 28, 2018, and a resin-based composite (D2391) on tooth #21
on July 8, 2019, and your amalgam and resin fillings benefits for tooth #'s 21, 28, & 29 has been exhausted.
Therefore, we decided that the Plan does not have to pre-approve resin-based composites (D2391) for tooth #'s
21, 28, & 29.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 18, 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 services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed,
however, the physician must clearly document, in the medical record, his or her intent that the test be
performed.
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided
that the Plan does not have to pay for the laboratory services provided on July 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant maintenance procedures (D6080) provided on January 6, 2020. 
 
You asked the Plan to pay for the implant maintenance procedures. You say that you have no natural teeth, but have mini implants, and a regular cleaning is necessary every six months to ensure a healthy mouth and gums. The Plan denied your request. The Plan says this service is not covered under your contract under any normal circumstances. 
 
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 implant maintenance procedures (D6080) provided on January 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve NuStep Recumbent Cross Trainer Bike.
You asked the Plan to pre-approve the recumbent bike. You say that due to COVID the enrollee is not able to
receive the needed therapy. She would greatly benefit using a seated recumbent bike to continue in home
therapy for strengthening of her extremities. The Plan denied your request. The Plan says this item is not
covered.
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 NuStep Recumbent Cross Trainer Bike.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consult with WW.
You asked the Plan to pre-approve a consult with WW. You say that this should be covered for the
enrollee. The Plan denied your request. The Plan says the enrollee does not have a qualifying condition.
The Plan must follow Medicare rules. Medicare rules say that medical nutrition therapy services (MNT) is
covered for certain beneficiaries who have diabetes or a renal disease.
We looked at the file and Medicare rules. The record does not show that the enrollee has diabetes or a renal
disease. Based on this information, we decided that Medicare rules for coverage of a consult with WWs have not been met. Therefore, we decided that the Plan does not have to pre-approve a consult with WW.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated post and core in addition to crown (D2954). 
 
You asked the Plan to pre-approve the prefabricated post and core in addition to crown. You say that the enrollee needs a post and core to build up the tooth prior to the crown seating. The Plan denied your request. The Plan says this service is not covered by Medicare. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a prefabricated post and core in addition to crown (D2954).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the CMS established defining criteria for an appropriate LTACH admission The Plan denied your request. The Plan says that needs can be met in a lower level of care such as IRF or even SNF, if the enrollee's medical and therapy needs are not complex.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee meets criteria based on need for specialized therapy, reasonable need for over 25 days stay, need for over 6.5 hours per day of nursing, inability to be able to be cared for at a lower level of care than LTACH. The services rendered by the LTACH will be suitable for the needs of this enrollee. This enrollee is requiring complex nursing, provider, and intravenous medication therapy that will be needed for over 25 days. 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 LTACH services have been met. Therefore, we decided that the Plan has to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
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 pre-approve the additional Allegra 60mg (99199).
You asked the Plan to pre-approve the additional Allegra 60mg. You say that you have allergies and needs to
take this daily. There is an allowance of $75 in a quarter and you cannot use it for what you really needs
because of the ridiculously low amount allowed. The Plan denied your request. The Plan says this request
exceeds the benefit limitation. Per the OTC catalog, Allegra 60 mg is limited to 3 boxes per calendar quarter
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and Allegra
60mg is an OTC item. However, the health plan has an over-the-counter benefit that exceeds Medicare
coverage. For that reason, the Plan's rules apply in this case. Though the Plan offers an over-the-counter
benefit in excess of Medicare coverage, the requested item exceeds the benefit limit. The health plan contract
says Allegra 60mg is limited to 3 boxes per quarter. The OTC benefit orders are limited to one per quarter.
Therefore, we decided that the Plan does not have to pre-approve the additional Allegra 60mg (99199).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve UBRELVY tablet.
You asked the Plan to pre-approve UBRELVY tablet. You say that you want the enrollee treated with this
drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B
benefit.
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 UBRELVY tablet.
Benefits for UBRELVY tablet 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 pre-approve an electrical bone growth stimulator.
You asked the Plan to pre-approve an electrical bone growth stimulator (E0747). You say that the enrollee
needs an electrical bone growth stimulator to heal a metatarsal fracture. The Plan denied your request. The Plan
says the there are no x-rays 90 days apart that show the bone is not healing.
The Plan must follow Medicare rules. The rules say that an electrical bone growth 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.
In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not
show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had
ceased. Therefore, we decided that the Plan does not have to pre-approve an electrical bone growth stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forknee orthosis (L1833) and sleeve (L2397) provided February 24, 2020.You asked the Plan to pay forthe orthoses. You say that medically necessary supplies was dispensed pursuant to physician orders, which were received by the enrollee.The Plan denied your request. The Plan says the services are not supported in the medical records received. The billed supply code cannot be verified.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 pay for the orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, and there is no credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.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 orthoses have not been met.Therefore, we decided that the Plan does not have to pay forknee orthosis (L1833) and sleeve (L2397) provided February 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide 180 additional routine transportation trips.
You asked the Plan to provide additional routine transportation trips. You say that you need transportation to get to your treatments. The Plan denied your request. The Plan says you have almost exhausted your benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 30 routine transportation one-way trips when 50 miles or less and scheduled in advance. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide 180 additional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe Magnetic Resonance Imaging (MRI) of the upper extremity (73221) provided March 7, 2020.You asked the Plan to waive the copayment forthe MRI. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.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 $75 copayment for Diagnostic Radiology. You have been asked to pay a $75 copayment for the MRI. The MRI falls within the Diagnostic Radiology benefitcategory. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe Magnetic Resonance Imaging (MRI) of the upper extremity (73221) provided March 7, 2020.