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

We decided that the Plan does not have to waive the copayment for laboratory services provided on February 5, 2020.You asked the Plan to waive the copayment for laboratory services. You say that you were informed you didn't have to pay for services that led up to your surgery. You say that you shouldn't have to pay the copayment.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 $40 copayment for each Medicare-covered laboratory test in an in-network outpatient hospital facility.You have been asked to pay a $40 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 February 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral exam (D0150) provided on January 17, 2020.You asked the Plan to pay forthe dental service. You say that you have not had a dental exam since 2017. You say that you received x-rays in 2018. You say that you are new to this provider and needed to have an exam. You also say that providers should be able to do an exam on a new patient.The Plan denied your request. The Plan says comprehensive oral exams are covered once every 3 years. The Plan also says that the frequency limit has been exceeded.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 applyin this case.Though the Plan offers a dental benefit in excess of Medicare coverage and comprehensive oral exams are a covered service, the frequency limit of once every 3 years has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on October 17, 2018.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral exam (D0150) provided on January 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2020) and lenses (V2100) purchased October 8, 2019.You asked the Plan to pay for the vision services. You say that in 2019 you purchased 2 pairs of eyeglasses for a total of $216. The plan covered only 1 claim for $108 and denied coverage for the second pair.The Plan denied your request. The Plan says only 1 pair of eyeglasses is covered per year and the benefit maximum has been exhausted.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers only 1 pair of eyeglasses or contact lenses and fitting per year.We looked at the file and the Plan's rules.  The plan only covers for 1 pair of eyeglasses or contact lenses and fitting per year. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay for deluxe frames (V2020) and lenses (V2100) purchased October 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) provided on January 21, 2020.You asked the Plan to pay for the extraction. You say that you called Medicare prior to this service being rendered and were told this would be covered. You also say that your tooth had broken off and infection was starting to set in.The Plan denied your request. The Plan says this service is not covered under your contract under any normal circumstances.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 extraction (D7140) provided on January 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gym membership fees reimbursement for January 1, 2019 to December 31, 2019.You asked the Plan to pay for gym membership fees. You say that you have previously turned down your application for reimbursement after many years of approving it. At the agents suggestion you are appealing and resubmitting the application.The Plan denied your request. The Plan says reimbursement for gym fee's is not covered under the plan benefits.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits to go to a Silver&Fit fitness club, YMCA or exercise center that takes part in the program. You can also participate in a home fitness program.The Plan's rules for coverage of gym benefits have not been met because reimbursement for gym fee's is not covered under the plan benefits.Therefore, we decided that the Plan does not have to pay for gym membership fees reimbursement for January 1, 2019 to December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe apicoectomy (D3425) and retrograde filling (D3430) provided on January 13, 2020.You asked the Plan to pay forthe apicoectomy and retrograde filling. You say that you spoke with a Plan representative who advised you that root canals were covered at 50% in-network and out-of-network.The Plan denied your request. The Plan says these services are not covered benefits under your dental plan. The Plan also says that these services that were rendered are not root canals.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 forthe apicoectomy (D3425) and retrograde filling (D3430) provided on January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam -two surfaces and amalgam -three surfaces provided on January 28, 2020 by an OON provider.You asked the Plan to pay for the amalgams. You say that you have been going to this provider for 25 years and have developed a trust with this provider.The Plan denied your request. The Plan says the treating provider is OON. The Plan also says that your plan does not cover out-of-network services unless the services are not available from an in-network dentist. 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 OON.Therefore, we decided that the Plan does not have to pay for the amalgam -two surfaces and amalgam -three surfaces provided on January 28, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 transmitter for the enrollee.You asked the Plan to pre-approve a DexcomG6 transmitter. You say that the enrollee would benefit from the monitor.The Plan denied your request. The Plan says that there is a lack of a trial of the preferred monitor or reason it is unable to be used.The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers. The requested CGM is not a preferred device with the plan. The Plan has specific brands for the item at issue in this appeal. We found no exception that would require the Plan to pre-approve the requested item.Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 transmitter for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe CT scan provided on January 22, 2020.You asked the Plan to waive the copayment forthe CT scan. You say that you were informed you didn't have to pay for services that led up to your surgery. You say that you shouldn't have to pay the copayment.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 $225 copayment for each in-network, Medicare-covered advanced imaging service. You have been asked to pay $102.73, which is less than the standard $225 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests andtherapeutic 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 forthe CT scan provided on January 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive interface.You asked the Plan to pre-approvea home ventilator, any type, used with non-invasive interface (E0466). You say that if the home vent is not approved the enrollee may relapse.The Plan denied your request. The Plan says clinical records do not meet medical necessity for a home vent.The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.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 a home ventilator, any type, used with non-invasive interface (E0466). Our reviewer says that a home ventilator is not medically necessary. Our physician reviewer found coverage criteria for a home ventilator are not met. This enrollee has COPD with hypoxemia.  The severity of the COPD is unclear; no pulmonary function data are provided. The enrollee also has obstructive sleep apnea and possible obesity hypoventilation syndrome. There are no arterial blood gas data documenting elevation of pCO2 in a stable state.  There is no documentation of failure of BiPAP. Certain BiPAP devices are capable of providing the AVAPS mode of ventilation ordered for this enrollee.  Medicare does not cover a home ventilator when used as a BiPAP device.  A home ventilator is not medically necessary, and the denial is upheld.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator, any type, used with non-invasive interface (E0466) have not been met.Therefore, we decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive interface.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 29, 2019.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says this claim should be submitted to Original Medicare for review due to the enrollee's hospice status at the time of service.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on December 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature and power standing feature.You asked the Plan to pre-approve a power seat elevation feature and power standing feature. The Plan denied your request. The Plan says that these items are not primarily medical in nature.The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature and power standing feature are non-covered because they are not primarily medical in nature.Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature and power standing feature.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring System.You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee needs to check insulin levels several times a day.The Plan denied your request. The Plan says the enrollee is not insulin treated three or more times a day or is frequently adjusting the insulin regimen.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at review the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring System.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Fasenra Pen, 30mg/ml.You asked the Plan to pre-approve the Fasenra Pen. The Plan denied your request. The Plan says the requested Fasenra Pen is a self-administered drug. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan says the Fasenra Pen is not covered under Medicare Part B.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 the Fasenra Pen, 30mg/ml.Benefits for the Fasenra Pen 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided on December 17, 2019 and December 24, 2019.You asked the Plan to waive the copayment for physical therapy. You say that you were informed the copayment was $30. You say that you want a refund.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 $40 copayment for each Medicare-covered physical therapy and/or speech and language pathology visit.You have been asked to pay a $40 copayment for each for physical therapy visit. The total amount you owe is $80 ($40/visit x 2 visits = $80). Physical therapy falls within the "Outpatient rehabilitation 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 physical therapy provided on December 17, 2019 and December 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two pontics and three retainer crowns.You asked the Plan to pre-approve the pontics and retainer crowns. You say that a denture would not work because you have a strong gag reflex. You also say that you have arthritis in your hands and cannot hold items securely.The Plan denied your request. The Plan says the documentation fails to indicate or support any specific physical or psychological condition(s) that preclude the use of a removable prosthesis.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 and retainer crowns 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 and retainer crowns. Our reviewer says that he criteria for fixed bridgework under the Plan has not been met. Our physician reviewer found the Plan requires that fixed bridgework to be considered in cases where the patient has a physical or psychological condition that precludes the use of a removable appliance. In this instance you have noted that you suffer from arthritis and have a strong gag reflex. Our reviewer found that in the general population arthritis is a very common affliction, and more advanced disease that limits hand function would have to be documented by a physician. Gag reflexes are common as well, and as this would be a partial denture and not a full denture the boarders of the appliance can easily be designed to avoid those areas that typically trigger a gag reflex response. Our physician reviewer also found that there have been no medical records showing a physical or psychological condition that would prevent the use of a removable appliance that can avoid the usual gag reflex trigger areas.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 and retainer crowns have not been met.Therefore, we decided that the Plan does not have to pre-approve two pontics and three retainer crowns.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe endoscopy provided on February 4, 2020.You asked the Plan to waive the copayment forthe endoscopy. You say that you weren't informed this would be considered diagnostic. You say that the test was totally normal.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 $325 copayment for surgical services at an in-network outpatient hospital facility.You have been asked to pay a $325 copayment for the endoscopy. The endoscopy 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 forthe endoscopy provided on February 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve13 additional physical therapy visits.You asked the Plan to pre-approve13 additional physical therapy visits. You say that the enrollee still needs therapy.The Plan denied your request. The Plan says further visits are not necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 13 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested 13 more visits of supervised physical therapy is generally not accepted as specific and effective therapy for the patient's condition. The patient has shown slow improvement over extensive therapy sessions and at this point is versed in a home exercise program. Her functional level is such that she does not need ongoing skilled therapy. The records do not demonstrate that the ongoing unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested 13 therapy visits are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 13 additional physical therapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approve13 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a personal foot massage device.You asked the Plan to pre-approve massage device. You say that this foot massager is cheaper than therapy.The Plan denied your request. The Plan says the denial of authorization for this device is correct, because a foot massager is not covered by Medicare.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve a personal foot massage device.