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

We decided that the Plan does not have to pay for the resin-based composite provided by an OON provider on October 10, 2019.
You asked the Plan to pay for the resin-based composite. You say that you were not aware that this provider was not in network with your Plan. You also say this provider did not inform you that they were out-of-network. The Plan denied your request. The Plan says this service was performed by a non-participating provider. The Plan also says that a call was not made to the Plan prior to this date of service to verify the provider's participation status.
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, you are responsible for a 55% coinsurance for restorations when they are received out-of-network. The Plan is only obligated to pay 45% coinsurance for restorations. The record shows that the Plan paid 50% coinsurance and you are responsible for the remaining 50% coinsurance. Therefore, we decided that the Plan does not have to pay for the resin-based composite provided by an OON provider on October 10, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the copayment fora cervical and vaginal cancer screening provided on September 10, 2019.You asked the Plan to waive the copayment fora cervical and vaginal cancer screening. You say that this was a preventative screening and you disagree with the charges.The Plan denied your request. The Plan says that the claims were processedcorrectly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is no coinsurance, copayment or deductible for a cervical and vaginal cancer screening.The medical records show that you received a cervical and vaginal cancer screening on September 10, 2019. Therefore, you do not owe a copayment for the services.  The Plan says you must pay a $10 copayment fora cervical and vaginal cancer screening. Based on the Plan contract, however, you cannot be asked to pay for a cervical and vaginal cancer screening.Therefore, we decided that the Plan has to waive the copayment fora cervical and vaginal cancer screening provided September 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on October 18, 2019 and October 21, 2019.
You asked the Plan to waive the copayment for the ED visits. You say that your diagnosis should have stated why your hip was hurting. You say that you don't feel responsible for the copayments. The Plan denied your request. The Plan says the copayments 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 $65 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $65 copayment for each ED visit. The total amount you owe is $130 ($65/visit x 2 visits = $130). The ED visits falls within the "Emergency care" benefit category. The records show that you were treated during each ED 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 ED visit provided on October 18, 2019 and October 21, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on October 20, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you were told by the physician that you would not be charged for the ambulance transport because you were transferred form one facility to another facility. 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 $250 copayment for Medicare-covered ambulance benefits. You have been asked to pay a $250 copayment for the ambulance ride. The ambulance ride falls within the "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 ride provided on October 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. You say that the in-network provider is incompetent because the provider could not find the cataracts. The Plan denied your request. The Plan says the service is available within the primary network and not an emergency.
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 the requested physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services.You asked the Plan to pre-approve physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care 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. Thecontract 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 nota 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat facet joint injections.
You asked the Plan to pre-approve the repeat injections. You say that the enrollee should be allowed to have these injections. The Plan denied your request. The Plan says the criteria for the requested treatment are not met.
The Plan follows Medicare rules. Medicare rules say that repeat facet joint injections may be considered reasonable and necessary when prior injections have produced at least 50% pain relief. 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 repeat injections. Our reviewer says that the requested facet joint injections are not considered medically reasonable and necessary. Our physician reviewer found the patient has chronic low back pain due to spinal stenosis with lumbar radiculopathy and facet arthropathy. The patient has had epidural steroid injections as well as diagnostic facet blocks. The pain dairy entries do not support the statements in the progress notes. The patient has failed to achieve 50% pain relief. The patient also has persistent lumbar radiculopathy which does not meet LCD criteria. 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 repeat injections have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat facet joint injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDurolane injections for the enrollee.You asked the Plan to pre-approveDurolane. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Durolane. Our reviewer says that Durolane is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc or that they would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Durolane.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met.Therefore, we decided that the Plan does not have to pre-approveDurolane injections for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea seat lift recliner.You asked the Plan to pre-approvea seat lift recliner. You say that the enrollee's doctor ordered a power lift recliner chair so the enrollee can sit comfortably and would not need assistance during the day. The Plan denied your request. The Plan says Medicare does not cover seat lift chairs only the seat lift mechanism.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed are met.The rules say that seat lift chairs are not covered. Coverage is limited to a seat lift mechanism.We looked at the file and Medicare rules.Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide coverage only for items that Medicare covers.Therefore, we decided that the Plan does not have to pre-approvea seat lift recliner.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Flexitouch pneumatic compression device and appliances
You asked the Plan to provide a pneumatic compression device (E0652) and appliances (E0667). You say that the enrollee tried a basic pump but it did not provide improvement. The Plan denied your request. The Plan says the enrollee has not had a 4 week trial with a basic pump.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to provide a Flexitouch pneumatic compression
device and appliances
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve percutaneous implantation of neurostimulator electrode array for the enrollee.You asked the Planto pre-approvethe procedure. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requirements have not been met.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 the procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found there has not been demonstration of pain relief with a temporarily implanted electrode.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 procedure have not been met.Therefore, we decided that the Plandoes not haveto pre-approvepercutaneous implantation of neurostimulator electrode array for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea Flexitouch pneumatic compression device and appliances.You asked the Plan to providea pneumatic compression device (E0652) and appliances (E0667). You say that a basic pump was ruled out during trial because it displaced the edema and caused no improvement.The Plan denied your request. The Plan says the enrollee has not had a 4-week trial with a basic pump.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does nothave to providea Flexitouch pneumatic compression device and appliances.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three pontics (D6242), seven custom fabricated abutments (D6057), seven endosteal implants (D6010), and seven abutment supported retainers (D6071).You asked the Plan to pre-approve the pontics, custom fabricated abutments, endosteal implants, and abutment supported retainers. You say that the enrollee's chewing ability is greatly decreased due to the poor condition of her back teeth, and will be worse once those teeth are extracted. You also say that dental implants would improve the enrollee's chewing ability and allow her better nutrition.The Plan denied your request. The Plan says abutment supported retainer (D6071) is not a covered benefit. The Plan also says that the services did not demonstrate medical necessity.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. The Plan covers the pontics, custom fabricated abutments, endosteal implants, and abutment supported retainers when the services are medically necessary and reasonable. 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 pontics, custom fabricated abutments, endosteal implants, and abutment supported retainers. Our reviewer says that the services are not medically necessary. Our physician reviewer found the existing six unit anterior bridge has failing abutments on tooth #'s 6 and 11 which is stated to require removal, as well as #2 and #4. Our physician reviewer found that tooth #4 appears to have had endodontic treatment and a crown, tooth #2 appears to have a standard restoration. The bone support appears to be reasonable around both of these teeth, and no clear need for the removal of these teeth as has been stated by the provider. Our reviewer found that this enrollee has not been wearing a denture currently, or has attempted to wear one over a two year period of time. There is no indication of any extenuating circumstances, as the enrollee if being treated for medically managed conditions including diabetes which does not preclude the use of a removable appliance. Our reviewer found that given the criteria of the Policy, there has been no showing of medical necessity for the requested implant procedures.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the pontics, custom fabricated abutments, endosteal implants, and abutment supported retainers have not been met.Therefore, we decided that the Plan does not have to pre-approve three pontics (D6242), seven custom fabricated abutments (D6057), seven endosteal implants (D6010), and seven abutment supported retainers (D6071).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sensipar 30mg for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the service in question is not covered under any normal circumstances.

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 Sensipar 30mg for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the chiropractic manipulations provided
from August 21, 2019 to September 16, 2019.
You asked the Plan to waive the copayments for the chiropractic manipulations. You say that you would like to
be reimbursed. 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 $45
copayment for out-of-network Medicare-covered services when using your POS benefit.
You have been asked to pay a total of $103.25 copayment for the chiropractic manipulations. The chiropractic
manipulations fall within the "Chiropractic services" benefit category. See chart below.
Date of Service Service Allowed Amount Copayment Member Liability
August 21, 2019 Chiropractic
manipulation
$37.98 $45.00 $37.98
August 28, 2019 Chiropractic
manipulation
$27.29 $45.00 $27.29
September 16, 2019 Chiropractic
manipulation
$37.98 $45.00 $37.98
Total $103.25
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 chiropractic manipulations provided from August 21,
2019 to September 16, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran urgent care visit provided on October 19, 2019.You asked the Plan to waive the copayment foran urgent care visit. You say that you disagree with the charges because you only saw the doctor for a minute.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must discloseto 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 urgently needed services. You have been asked to paya $50 copayment for an urgent care visit. An urgent care visit falls within the urgently needed 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 foran urgent care visit provided on October 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 23,
2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be
covered.
The documentation submitted did not include a physician order/lab requisition or medical records stating
exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of
the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing
services provided to the enrollee on April 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you want to appeal the Plan's denial of the requested orthotics.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
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 it is unreasonable that the ambulance service was not covered because they decided not to take the enrollee. You say the enrollee fell and hit her head so you called for paramedics. In previous instances, you say the enrollee has had to go to the hospital. You say that in this particular instance, the enrollee did end up needing to go to the hospital 36 hours later.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 October 7, 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 forthe ambulance services.