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

We decided that the Plan does not have to pre-approve Saxenda.
You asked the Plan to pre-approve Saxenda. You say that the enrollee has failed other medications. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D prescription drug plan.
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 Saxenda.
Benefits for Saxenda 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 for the services rendered to the enrollee from April 8, 2019 to April 15, 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 services are not covered when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The provider submitted claims for procedure code 97039 (unlisted physical therapy modality). Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee from April 8, 2019 to April 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on November 15, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that your physician requested the transport and you wanted your family to take you instead. The Plan denied your request. The Plan says that you are contractually obligated to pay a copayment for ambulance transports.
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 $225 copayment for each separate Medicare-covered ambulance service. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered ambulance service 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 November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe moderate sedation services beyond the first 15 minutes provided on October 8, 2019 billed with code 99153.You asked the Plan to pay forthe moderate sedation services billed. You say that this claim should be paid as billed.The Plan denied your request. The Plan says separate payment cannot be made to the physician for this code when provided in the facility setting.Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid to the physician when provided in the facility setting. The Outpatient Prospective Payment System (OPPS) applies to all hospital outpatient departments.We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT code 99153 under the OPPS when performed in the facility setting.Therefore, we decided that the Plan does not have to pay forthe moderate sedation services beyond the first 15 minutes provided on October 8, 2019 billed with code 99153
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device to be provided by provider.You asked the Plan to pre-approve the powered upper extremity range of motion assist device (L8702).You say that this device would restore function to the dysfunctional arm and the ability to perform activities of daily living.The Plan denied your request. The Plan says a review of the current medical literature indicates that this device is considered experimental and investigational.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Items and services are furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the enrollee's condition or to improve the function of a malformed body member and one that meets but does not exceed the enrollee's medical need.We looked at the file and Medicare rules. There is insufficient medical record information submitted to show this orthosis would be preferred or more effective than the traditional upper orthosis types that are covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the powered upper extremity range of motion assist device (L8702) have not been met.Therefore, we decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device to be provided by provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on April 12, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing time frame.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the services was not filed until August 20, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for the services provided on April 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit services provided to the enrollee on June 24, 2019 to July 17, 2019.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says you self-referred to a provider who has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office visit services provided to the enrollee on June 24, 2019 to July 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride provided on October 28, 2019.
You asked the Plan to pay for the topical application of fluoride. You say that this provider has acquired your previous dentist's patients because your previous dentist left. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
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 topical application of fluoride provided on October 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the reline complete lower denture provided on October 16, 2019.You asked the Plan to pay more for the reline complete lower denture. You say that you were informed that the Plan would reimburse you. You say that you were only reimbursed half of what you paid.The Plan denied your request. The Plan says anything above the allowable amount remains your financial responsibility.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 the difference between the billed amount and allowed amount for out-of-network dental services. Therefore, we decided that the Plan does not have to pay more for the reline complete lower denture provided on October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203), the removal of a deep bone implant (20681), the repair of a facial bone with bone graft (21210), and the removal of facial bones (21026) provided from September 12, 2019 to October 3, 2019 by the out of network provider.You asked the Plan to pay for the dental services. You say that the dental services you received were a matter of emergency and not for cosmetic reasons. You say that your primary care physician's office advised you should get permission from them before you received the services.  You also say that the services were emergent so you needed the services to be done by the provider who you originally saw 20 years ago.The Plan denied your request. The Plan says dental services are not covered when you receive them out of network. The Plan also says that the provider in this case is not a network provider.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, dental services are only covered when you receive them from a contracted provider.Therefore, we decided that the Plan does not have to pay forthe office visit (99203), the removal of a deep bone implant (20681), the repair of a facial bone with bone graft (21210), and the removal of facial bones (21026) provided from September 12, 2019 to October3, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on September 3, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that the laboratory services were taken as part of an annual wellness exam and you have never been charged in the past. 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 disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for laboratory tests. You received laboratory services on September 3, 2019. Laboratory services are not included in an annual wellness exam. Therefore, you are responsible to pay the $20 copayment. You have been asked to pay a $20 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and 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 copayment for laboratory services provided on September 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on June 25, 2019.You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the documentation does not state exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that 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.In this case, the CPT Code Manual definition of code G0481 is definitive drug testing of 8-14 drug classes. We find that CPT code G0481 is not supported in the records. Specifically, there is no evidence that shows the test was individualized to identify 8-14specific non-prescribed medications or illicit substances. The records provided do not document concerns based on clinical review and judgement.Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on June 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on October 28, 2019.
You asked the Plan to pay for the dental service. You say that you needed an x-ray so that the dentist could determine what was causing your pain. You say that you have $150 in comprehensive coverage and therefore the service should be paid for. The Plan denied your request. The Plan says periapical x-rays are not a covered service.
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 periapical x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on October 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xolair.
You asked the Plan to pre-approve Xolair. You say that the Xolair is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Xolair. Our reviewer says that the Xolair is not medically necessary. Our physician reviewer found no pulmonary function testing data was provided. The primary symptoms appear to be related to rhinosinusitis rather than breathing. There is no consideration of desensitization therapy. Xolair is indicated and covered for allergic asthma, not COPD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xolair have not been met. Therefore, we decided that the Plan does not have to pre-approve Xolair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan provided on October 3, 2019.You asked the Plan to waive the copayment for the duplex scan. You say that you did not visit the office or have the scan performed.The Plan denied your request. The Plan says the copayment 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 $10 copayment per visit for laboratory tests, non-radiological tests, diagnostic tests, and ultrasounds.You have been asked to pay a $10 copayment for the duplex scan. The duplex scan falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for the duplex scan provided on October 3, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cancer panel provided on July 17, 2019.You asked the Plan to pay for the testing services. You say that the enrollee would benefit from the screening.The Plan denied your request. The Plan says the enrollee did not have any signs or symptoms to indicate the tests were necessary.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal was requested for screening purposes. In this case, there were insufficient records provided to show the results of this testing would be used to determine a specific diagnosis or determine a specific treatment strategy for disease or illness present in the enrollee at the time of service. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cancer panel provided on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99233) provided on August 6, 2019.
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the medical necessity of the services rendered.
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. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have not been met. Specifically, the record does not include any clinical information to confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99233) provided on August 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a Pattern Electroretinogram (92133) provided on August 23, 2019.
You asked the Plan to pay for the Electroretinogram. You say that the service was medically necessary. The Plan denied your request. The Plan says coverage criteria was not 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 pay for the Electroretinogram. Our reviewer says that the service at issue was not medically necessary. Our physician reviewer found Pattern Electroretinogram (PERG) is not considered standard of care in diagnosing or monitoring glaucoma. In general, this test is mostly used in detecting and distinguishing hereditary retinal dystrophies. 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 Electroretinogram have not been met. Therefore, we decided that the Plan does not have to pay for a Pattern Electroretinogram (92133) provided on August 23, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on October 1, 2018.
You asked the Plan to waive the copayment for an EGD. You say that you disagree with the charges. 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 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 $275 copayment for surgery services provided in an ambulatory surgical center. You received an EGD at an ambulatory surgical center on October 1, 2018. An EGD is considered an outpatient surgical procedure and is not included in a colonoscopy screening. Therefore, you are responsible to pay the $275 copayment. You have been asked to pay a $275 copayment for an EGD. An EGD falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 EGD provided on October 1, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent 150mg/ml pen for the enrollee.
You asked the Plan to pre-approve the pen. You say that this is medically necessary. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
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 Praluent 150mg/ml pen for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the one extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and extraction, erupted tooth or exposed root provided on October 11, 2019.
You asked the Plan to pay for one extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and extraction, erupted tooth or exposed root provided on October 11, 2019. You say that you thought the nitrous would be covered due to having a tooth extracted. The Plan denied your request. The Plan says your EOC provides a benefit for two extractions per calendar year and these have already been approved. The Plan also says that your benefit is 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, extractions are limited to two procedures per calendar year. The record shows that you received extractions on October 7, 2019 and October 11, 2019 and your extractions benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the one extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and extraction, erupted tooth or exposed root provided on October 11, 2019.
Your complaint about the Plan being wrong not to cover nitrous is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints