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

We decided that the Plan does not have to pay for the panoramic x-ray (D0330), initial intraoral x-ray (D0230), additional intraoral x-ray (D0230), and the office visit for observation (D9430) provided from July 17, 2019 to July 31, 2019.
You asked the Plan to pay for the panoramic x-ray, office visit for observation, and 2 intraoral x-rays. You say that you told the provider's office that you only wanted dental services that would be covered by the Plan. You say that before every visit you asked if the services would be covered. You say that the provider advised the services would be covered. You also say that the provider office should not be trusted. The Plan denied your request. The Plan says the panoramic x-ray, intraoral x-rays, and office visit for observation 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 panoramic x-rays, intraoral x-rays, and office visit for observation are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330), initial intraoral x-ray (D0230), additional intraoral x-ray (D0230), and the office visit for observation (D9430) provided from July 17, 2019 to July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye examination provided by the physician on July 10, 2019.
You asked the Plan to waive the copayment for eye exam. You say that this was a follow-up examination, and
if you had known there was a 90-day timeframe for this you would have scheduled the follow-up sooner. The
Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $30
copayment for eye exam.
You have been asked to pay $30 copayment for eye exam. eye exam falls within the Vision Care 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 eye examination provided by the physician on July 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 8, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee 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 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 physician's services provided on April 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 27, 2019.
You asked the Plan to pay for the physician's 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 service 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 physician's services provided on August 27, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (J0885).
You asked the Plan to pre-approve Procrit. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.
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 Procrit. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Retacrit would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit (J0885).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided by the out of network provider fom October 2, 2019 to October 11, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the services were provided by an out of network provider without prior authorization. There are in-network providers available that could have provided the 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 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. 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 the chiropractic manipulative treatment (98941) provided by the out of network provider from October 2, 2019 to October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by the physician on September 16, 2019.
You asked the Plan to waive the copayment for an office visit. You say that you went for a wellness visit to talk about getting taken off a medication. 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 $10 copayment for physician/practitioner services/PCP. You have been asked to pay a $10 copayment for an office visit. When additional services/services that go beyond an annual wellness exam are provided, an office visit copayment is applied. An office visit falls within the physician/practitioner services/PCP 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 office visit provided by the physician on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 10, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there is no valid referral for this service.
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 service 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 physician's services provided on June 10, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for services provided on June 3, 2018.
You asked the Plan to pay for the ambulance services. You say that the service was medically necessary. The Plan denied your request. The Plan says that the service was not authorized.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit medical documentation or a trip ticket to support the denial. Therefore, we decided that the Plan has to pay for services provided  on June 3, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the deep sedation, first 15 minutes (D9222), deep sedation, additional 15 minutes (D9223 x 2), and the therapeutic parenteral drug (D9610) provided on October 17, 2019.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the dental services you received are not listed as covered services. The Plan also says that you were notified before receiving the services that they would not be 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. Therefore, we decided that the Plan does not have to pay for the deep sedation, first 15 minutes (D9222), deep sedation, additional 15 minutes (D9223 x 2), and the therapeutic parenteral drug (D9610) provided on October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for miscellaneous durable medical equipment (E1399 LT RT) provided October 11, 2019.
You asked the Plan to pay for miscellaneous durable medical equipment. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not support the supplies billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order, an itemized shipping/billing invoice to indicate the specific supplies, and proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for miscellaneous durable medical equipment (E1399 LT RT) provided on October 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0642) provided to the enrollee on June 11, 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 documentation submitted did not support the diagnosis used on the submitted order, nor did the documentation 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. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order for the supplies provided in this case. The documentation does not discuss the need for the billed code. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0642) provided to the enrollee on June 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, bone replacement graft, bitewing x-ray, problem focused limited oral evaluation, and first intraoral periapical x-ray provided on June 18, 2019.

You asked the Plan to pay for the dental services. You say that you were in severe pain and dental surgery was required. You also say that you did not have time to receive a prior authorization due to the pain that was quickly becoming worse. The Plan denied your request. The Plan says you received non-Medicare covered dental services. The Plan also says that Medicare does not cover dental services unless they are in preparation for medical services.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the extraction, bone replacement graft, bitewing x-ray, problem focused limited oral evaluation, and first intraoral periapical x-ray provided on June 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 7 surgical extraction (D7210) provided on April 18, 2019.
You asked the Plan to pay for the dental services. You say that you are unable to have dental implants due to bone loss in your jaw. You say that extractions were the only option. The Plan denied your request. The Plan says surgical extractions 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, surgical extractions are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 7 surgical extraction (D7210) provided on April 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on July 10, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered to the enrollee on July 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional extraction provided on August 14, 2019.
You asked the Plan to pay for the additional extraction. You say that you were not told by the provider that he was extracting both of your teeth. You also say that you would like to be reimbursed for the entire bill. The Plan denied your request. The Plan says services performed by an out-of-network provider are not covered because your healthcare plan does not have out-of-network benefits.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the additional extraction provided on August 14, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from August 1, 2018 to August 31, 2018.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are missing required information.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim is required to have the appropriate Q code to processed and pay the claim. Review of the file shows that this claim was not submitted with the appropriate Q code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from August 1, 2018 to August 31, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 26, 2019 by an out of network provider.
You asked the Plan to pay for the interrogation device evaluations (93296 and 93294). You say that the services provided were medically necessary. The Plan denied your request. The Plan says services rendered by non-participating 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 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 26, 2019 by an out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the remaining 3 units of CPT codes 81340 and 81342 and the remaining 2 units of CPT code 88341 provided on June 6, 2019.
You asked the Plan to pay for the remaining 3 units of CPT codes 81340 and 81342 and the remaining 2 units of CPT code 88341. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not supported as billed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT codes 81340 and 81342 is 1. You billed 4 units of each of these codes, exceeding the MUE. The MUE for CPT code 88341 is 13. You billed 15 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the remaining 3 units of CPT codes 81340 and 81342 and the remaining 2 units of CPT code 88341 have not been met. Therefore, we decided that the Plan does not have to pay for the remaining 3 units of CPT codes 81340 and 81342 and the remaining 2 units of CPT code 88341 provided on June 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the tocilizumab injections rendered to you from February 15, 2019 to August 2, 2019.
You asked the Plan to waive the coinsurance for these services. You say that the plan should pay the bills. The Plan denied your request. The Plan says the coinsurance was 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 20% coinsurance for Medicare Part B non-chemotherapy prescription drugs.
Review of the file shows that you received tocilizumab injections for seven dates of service from February 15, 2019 to August 2, 2019. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare Part B non-chemotherapy 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 for the tocilizumab injections rendered to you from February 15, 2019 to August 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued on August 27, 2019.
You asked the Plan to pay for the compression stockings. You say that you were prescribed these stockings and they are only available from a prescription. The Plan denied your request. The Plan says gradient compression stockings are reasonable and necessary only when it covers a surgical wound.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6533 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued on August 27, 2019.