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

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous GlucoseMonitoring (CGM) system.You asked the Plan to pre-approvea CGM. You say that the enrollee would benefit from a CGM.The Plan denied your request. The Plan says the enrollee is not insulin treated three or more times a day.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. The record shows the enrollee is not insulin injecting three or more times a day or testing four or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met.Therefore, we decided that the Plan does not have to pre-approvea FreeStyle Libre Continuous Glucose Monitoring (CGM) system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Self-administered drugs (A9270) provided August 13 to August 18, 2019. You asked the Plan to pay for the self-administered drugs. You say that the drugs should be covered.The Plan denied your request. The Plan says self-administered drugs provided in the outpatient hospital setting are generally not eligible for coverage under the Part B medical benefit. Benefits may be available under Part D coverage.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 pay for Self-administered drugs (A9270) provided August 13 to August 18, 2019. Benefits for the 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental consultation (D9310) you received on November 5, 2019.You asked the Plan to pay forthe dental services. You say that this is not a dental service.The Plan denied your request. The Plan says only preventive dental services are 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 services arenot among those covered under this benefit. The plan only covers preventive dental services. The requested consultation (D9310) is not considered a preventive dental services, and therefore is not covered.Therefore, we decided that the Plan does not have to pay forthe dental consultation (D9310) you received on November 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a TENS device.
You asked the Plan to pre-approve a TENS device. You say that a TENS device will help the enrollee to
manage chronic pain without using medication. The Plan denied your request. The Plan says the enrollee is not
enrolled in a 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. 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 preapprove
a TENS device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed. You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee needs a total electric hospital bed. The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare or the Plan. The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the doctor.You asked the Plan to pre-approve the physician's services. You say that you would like to see this physician because of his special skill set with prolapse repair and stress urinary incontinence. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the doctor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that the plan requires the enrollee to receive care from providers who are part of the enrollee's primary care physician's (PCP) specialty 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 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 contract with the Plan also says that the plan requires the enrollee to receive care from providers who are part of the enrollee's primary care physician's (PCP) specialty network.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from October
3, 2019 to October 29, 2019.
You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says the claim submitted has an invalid place of service code. The Plan must
follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report
services with the appropriate POS code. In this case, the claim submitted has errors with the POS code
preventing payment. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have
to pay for home health services provided to the enrollee from October 3, 2019 to October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveradiofrequency ablations for sacroiliac joint pain.You asked the Plan to pre-approveradiofrequency ablations. You say that this is necessary because other treatments have failed.The Plan denied your request. The Plan says this is not a covered procedure.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that radiofrequency ablation used for sacro-iliac joint pain is considered not medically necessary/investigational.We looked at the file and Medicare rules. The requested procedure is considered not medically necessary under Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablations have not been met.Therefore, we decided that the Plan does not have to pre-approveradiofrequency ablations for sacroiliac joint pain.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endosteal implants (D6010), custom fabricated
abutments (D6057), and abutment supported crowns (D6058) for teeth # 29 and 30.
You asked the Plan to pre-approve the dental services. You say that the enrollee has an upper denture that rocks
when chewing due to no opposing structure on the lower right side. You say that a minimum of one implant,
for tooth # 29, should be covered to aid in balancing the enrollee's opposing prosthetic and better his quality of
life. The Plan denied your request. The Plan says endosteal implants, custom fabricated abutments, and
abutment supported crowns are not listed as covered services.
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 dental services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
endosteal implants (D6010), custom fabricated abutments (D6057), and abutment supported crowns (D6058)
for teeth # 29 and 30.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 27, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you did not know this provider was not in-network, and
you are unable to pay this expense. The Plan denied your request. The Plan says the denial of payment for this
service is correct, because this provider is out-of-network with the Plan and this visit was not urgent or
emergent in nature.
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 medical services provided on September 27,
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 3, 2019 to October 16, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe nursing facility care (99308) and debridement (11046) provided on October 3, 2019 through October 16, 2019. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan saysservices provided by non-participating providers are excluded.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 incases 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 medical services provided on October 3, 2019 to October 16, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 24, 2019 to the enrollee by a non-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 medical services provided on September 24, 2019 to the enrollee by a non-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance transports provided on August 24, 2019, August 27, 2019, August 30, 2019, September 14, 2019 and October 9, 2019.
You asked the Plan to waive the copayments for the ambulance transports. You say that these transports should have been covered by your insurance. The Plan denied your request. The Plan says that cost sharing is a contractual obligation under the plan and cannot be waived.
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 $250 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $1250 copayment for the ambulance transports. The ambulance transports fall within the one-way Medicare-covered ground trip benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the ambulance transports provided on August 24, 2019, August 27, 2019, August 30, 2019, September 14, 2019 and October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 26, 2019 to the enrollee by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-participating provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 medical services provided on August 26, 2019
to the enrollee by a non-participating provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the emergency response services were medically necessary. You say that you were having extreme chest pain and experiencing a lot of stress and anxiety. You believed that you were having a heart attack and called 911 for emergency assistance. After the paramedics arrived and monitored your vitals for a while, they concluded that you were not experiencing a cardiovascular event but instead a severe panic attack. You were offered transportation however you declined in order to spare yourself additional stress and expense. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on March 18, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 28, 2019.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The Plan says that the copayment was accessed correctly per the plan 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). Your contract with the Plan clearly says that you must pay a $250 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ground trip 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 October 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe Guardant360 laboratory panel provided to the enrollee on August 8, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysexperimental or investigational services are not covered.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 services. Our reviewer says that the services at issue in this case are not medically reasonable or necessary. Our physician reviewer found per the reviewed documentation, there is no documentation of a new primary cancer diagnosis. The review has determined that the enrollee did not meet the criteria for the test performed on August 8, 2019.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 services have not been met.Therefore, we decided that the Plandoes not haveto pay forthe Guardant360 laboratory panel provided to the enrollee on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forcustodial care services provided to the enrollee from June 5, 2019 to August 3, 2019.You asked the Planto pay forthe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered.The services received by the enrollee on the dates of servicein question are considered custodial care services. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forcustodial care services provided to the enrollee from June 5, 2019 to August 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulatory infusion pump provided July 15, 2019.You asked the Plan to pay forthe ambulatory infusion pump (E0781). You say that the Plan should pay this claim.The Plan denied your request. The Plan says The services performed by non-participating provider are inclusive under services approved and paid in Outpatient Prospective Payment System (OPPS) for treatment at par facility. Therefore, non-participating provider should bill the facility for services paid under OPPS.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Medicare's payment for administration of the drug billed to the MAC will also include payment for equipment used in furnishing the service.In this case, the CPT Code Manual definition of code E0781 is ambulatory infusion pump, single or multiple channels, electric or battery.Medicare's payment for the supplies billed to the MAC includes payment for the equipment and they are not separately payable. Based on this information, we decided that Medicare rules for coverage of the ambulatory infusion pump (E0781) have not been met.Therefore, we decided that the Plan does not have to pay forthe ambulatory infusion pump provided on July 15, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit and an inpatient hospital stay provided on August 27, 2019 to September 14, 2019.
You asked the Plan to waive the copayment for an emergency room visit and an inpatient hospital stay. You say that these bills should be covered by the Plan. The Plan denied your request. The Plan says the correct copayments have been 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 $90 copayment for emergency care and a $320 copayment per day for days 1-5 for inpatient hospital care/in-network. You have been asked to pay a $90 copayment and a $320 copayment per day for days 1-2. The total amount you are being asked to pay is $820 ($90 + $90 + $640 ($320 x 2 days) = $820). An emergency room visit falls within the emergency care benefit category. An inpatient hospital stay falls within the inpatient hospital care/in-network 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 an emergency room visit and an inpatient hospital stay provided on August 27, 2019 to September 14, 2019.