Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the deductible for the office visit and the venipuncture. We decided that the Plan does not have to waive the copayment for the office visit. You asked the Plan to waive the deductible for the office visit and the venipuncture. You say that this was your routine physical with laboratory work. You say you should not be responsible for any payment.The Plan says that you have been charged the correct cost sharing amount. We decided that the Plan has to waive the deductible for the office visit and the venipuncture. 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 does not say in clear and accurate terms how much you should expect to pay for the office visit and the venipuncture. We looked at your contract with the Plan. We did not see where the contract says that the deductible should apply to physician services. The Plan contract clearly saysthat physician and provider services do not apply to the deductible. The record shows that the office visit and the venipuncture are considered physician and professional services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the deductible for an office visit and venipuncture provided on October 24, 2019.We also decided that the Plan does not have to waive the copayment for the office visit.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 $5for each in-network primary care physician's office visit.The record shows diagnosis codes for conditions such as osteoporosis, hypothyroidism, irritable bowel syndrome, and anxiety disorders which makes this an office visit. Therefore, we decided that the Plan does not have to waive the copayment for the office visit.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 pay for the collection and application of autologous blood concentrate product (D7921), the sinus augmentation (D7952), and the implant (D6010) provided on October 24, 2019.You asked the Plan to pay for the dental services. You say that the dental services you received were medical in nature, not cosmetic.The Plan denied your request. The Plan says the dental services that you received are not listed as 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 dental services that you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the collection and application of autologous blood concentrate product (D7921),the sinus augmentation (D7952), and the implant (D6010) provided on October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services providedon November 30, 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 servicesat 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 providedon November30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Desloratadin for the enrollee.
You asked the Plan to pre-approve Desloratadin. You say that it is in the enrollee's best medical interest to continue the medication. The Plan denied your request. The Plan says Desloratadin to be taken at home is not covered under the Part B benefit.
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 Desloratadin for the enrollee.
Benefits for Desloratadin 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and the oral hygiene instruction (D1330) provided on January 3, 2020.
You asked the Plan to pay for the dental services. You say that you were advised you would not have to pay for the services. The Plan denied your request. The Plan says the dental services you received are preventive in nature. The Plan also says that preventive dental services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received are not among those covered under this benefit. The Evidence of Coverage clearly states that preventive dental services are not covered. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and the oral hygiene instruction (D1330) provided on January 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on December 13, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. The rules state that for any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered. The record shows that the Plan made several attempts to obtain documentation to validate an established relationship with the ordering physician, along with documentation of the duration of the patient's condition, clinical course (worsening or improving), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, and previously purchased DME items related to the billed items. The record does not include sufficient information to validate the service billed. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on December 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve application of amniotic membrane tissue on the ocular surface.You asked the Plan to pre-approve eye surgery. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is 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 eye surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has signs and symptoms of dry eye syndrome. She has signs of punctate keratitis that is associated with this condition. Amniotic membrane transplant is used in ocular surface reconstructions, pterygium excision, corneal ulcers, persistent epithelial defects, ocular surface burns, and various other ocular conditions. However, it is not indicated for dry eye syndrome.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of eye surgery have not been met.Therefore, we decided that the Plan does not have to pre-approve application of amniotic membrane tissue on the ocular surface.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copay for the physician services you received on October 16, 2019.
You asked the Plan to waive the copay for the services provided. You say that you were not in the provider's office. The Plan denied your request. The Plan says that the copay was applied for the services rendered.
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 does not say in clear and accurate terms how much you should expect to pay for the services at issue. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $45 copay for physician services during observation services. The medical records provided do not show that you received physician services in a specialist office. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copay for the physician services you received on October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the oral exam (D0120), cleaning (D1110), and bitewing x-rays (D0274) provided on October 11, 2019 by an out of network dentist.
You asked the Plan to pay the in network rate for the dental services. You say that you pay for the Platinum Dental Rider. You also say that the provider is in network at the address that you saw him. The Plan denied your request. The Plan says the provider in this case is not a network provider at the location that the services were rendered. The Plan says there is a higher cost sharing amount for the services that you receive out of network.
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 and the services you received are listed as covered, thy are subject to a higher cost sharing amount when you receive them out of network. The Provider Manual clearly shows that provider in this case is not in network at the location that you received the services. Additionally, the cost share is a contractual obligation of the plan and cannot be waived. Therefore, we decided that the Plan does not have to pay the in network rate for the oral exam (D0120), cleaning (D1110), and bitewing x-rays (D0274) provided on October 11, 2019 by an out of network dentist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on October 21, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.
Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on December 4, 2019.
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 claim was not billed correctly.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the claim for code 99214 was billed with incorrect diagnosis codes. The diagnosis codes that were billed indicate laterality when a more appropriate bilateral diagnosis is available. 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 office visit rendered on December 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of wireless pulmonary artery pressure sensor (CardioMEMS).
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee urgently needs this procedure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is considered experimental or investigational.
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 CardioMEMS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found therapy change based on data obtained from a CardioMEMS device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of CardioMEMS is uncertain at this time and not recommended in current guidelines for the treatment of heart failure. This device should still be considered experimental or investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of wireless pulmonary artery pressure sensor (CardioMEMS).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forinjections(96374) provided on September 29, 2019.You asked the Plan to pay forinjections. You say that you should be paid for these services.The Plan denied your request. The Plan says insufficient information was submitted to support payment.The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.We looked at the file and Medicare rules. Medical records and other supporting documentation were not submitted. Without this information, medical necessity cannot be established. Based on this information, we decided that Medicare rules for coverage of injections have not been met.Therefore, we decided that the Plan does not have to pay forinjections (96374) provided on September 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe IVIG treatment provided on November 21, 2019.You asked the Plan to waive the coinsurance forthe IVIG treatment. You say that this is not affordable.The Plan denied your request. The Plan says that you are responsible for 20% coinsurance.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% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the IVIG treatment. The IVIG treatment falls within the Medicare Part B prescription drugs 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 coinsurance forthe IVIG treatment provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hearing exam provided by an in-network provider on October 22, 2019.You asked the Plan to waive the copayment for a hearing exam. You say that you should have a free hearing test. You say that you should not owe anything for this visit.The Plan denied your request. The Plan says the correct copayment has 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 $40 copayment for hearing services-Medicare covered/hearing exam to determine medical treatment. You have been asked to pay a $40 copayment for a hearing exam. Evidence was provided to show that the correct copayment has been applied. Hearing exam falls within the hearing services-Medicare covered/hearing exam to determine medical treatment 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 a hearing exam provided by an in-network provider on October 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on December 12 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the Plan should pay this claim. The Plan denied your request. The Plan says documentation submitted did not indicate the provider discussed the need for the billed supply code, therefore 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 looked at the file and Medicare rules. There are no medical records supporting medical necessity for the orthosis. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on December 12 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 27, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items orderedand for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have topay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen supplies provided from December 10, 2019 to January 10, 2020. You asked the Plan to waive the coinsurance for the oxygen supplies. You say that you should not have to pay for oxygen. You say the insurance company should pay for all of it. 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 10% coinsurance for Medicare-covered items and related supplies. You have been asked to pay a total of $18.50 for the oxygen supplies. The oxygen supplies fall within the "Durable medical equipment (DME) and related supplies" 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 coinsurance for the oxygen supplies provided from December 10, 2019 to January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on July 22, 2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says out of area services are limited to urgent or emergent services.
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 on July 22, 2019.