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

We decided that the Plan does not have to pre-approve a partial lower denture (D5214).You asked the Plan to pre-approve the partial lower denture. The Plan denied your request. The Plan says a partial lower denture is not medically necessary.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 partial lower denture 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 partial lower denture. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation provided show that the enrollee was approved for an upper partial denture as well as endodontic treatment and crowns on several upper and lower teeth. After placement of the upper partial denture and restoration of the upper and lower teeth, there would be more than the minimum of 8 posterior contacts. Therefore the criteria for a lower partial denture would not be met and there would be no medical necessity. 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 partial lower denture have not been met.Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power operated vehicle (POV).You asked the Plan to pre-approvea Group 2 POV. You say that you need the scooter due to your disability.The Plan denied your request. The Plan says that the requested POV is never covered by Medicare.The Plan must follow Medicare rules. The rules say that Group 2 POVs are denied as not reasonable and necessary.  The item at issue is a Group 2 POV. This item is denied by Medicare for all indications. This means that Medicare rules for coverage of the POV have not been met.Therefore, we decided that the Plan does not have to pre-approvea Group 2 power operated vehicle (POV).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided April 2, 2019 to April 30, 2019.
You asked the Plan to pay for the SNF services. You say that in consideration of the services rendered, please reconsider the denial of the claim. The Plan denied your request. The Plan says the service was billed with an inappropriate modifier or service code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided April 2, 2019 to April 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Inogen G5 portable oxygen concentrator purchased on September 3, 2019.
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that you are unable to use your walker and lift and carry the portable tank in and out of the house. The Plan denied your request. The Plan says you did not request prior authorization for the portable oxygen concentrator from an out-of-network provider.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. Medicare rules say that only rented oxygen equipment is eligible for coverage.
The file shows that you had portable oxygen tank with wheels and carry pouch at the time the portable oxygen concentrator was purchased. The portable oxygen tank with wheels and carry pouch serves the same purpose as the portable oxygen concentrator at issue. Portable oxygen is provided for in-home needs and there is no record that your current portable tanks are not meeting your in-home needs. You did not request prior authorization. Purchased oxygen equipment is statutorily non-covered by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the Inogen G5 portable oxygen concentrator purchased on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (CPT 99152) provided to the enrollee on October 17, 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 Current Procedural Terminology (CPT) code 99152 remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99152 is "moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older." 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found while the enrollee received a pre-sedation screening, there is no evidence that the enrollee received any sort of moderate sedation. Therefore, the billing of CPT 99152 is not supported. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (CPT 99152) provided to the enrollee on October 17, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the ambulance transport provided on October 6, 2019.You asked the Plan to waive the cost share forthe ambulance transport. You say that you offered to drive yourself to the hospital. You say that they called for an ambulance. The Plan denied your request. The Plan says the cost share applied correctly.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 your in-network deductible is $300. This is the amount you have to pay out-of-pocket before we will pay our share for your covered in-network medical services.Your contract with the Plan says thatafter your yearly deductible is met, you pay $100 for each one-way Medicare-covered ambulance transport.The item or service you asked the Plan to waive the cost share for falls within the "Ambulance services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $300 deductible applies to ambulance services. This cost sharing is a contractual obligation that had not been met at the time the ambulance transport was received on October 6, 2019.Therefore, the remaining amount of $242.51 has been applied to the deductible.Since you met your deductible, you have also been asked to pay $22.94, which is less than the standard $100 copayment for the ambulance transport.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 cost share forthe ambulance transport provided on October 6, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from June 19, 2019 to August 7, 2019.
You asked the Plan to waive the copayments for the physical therapy visits. You say that you were not advised there would be a copayment for each visit. 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 $40 copayment per therapy type, per provider, per day for rehabilitation services. You have been asked to pay a $40 copayment for the each of the physical therapy visits. The physical therapy visits fall 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 copayments for the physical therapy visits provided by from June 19, 2019 to August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the outpatient clinic visits provided from April 2, 2019 to December 30, 2019.You asked the Plan to reduce the copayment forthe outpatient clinic visits. You say that you should only be charged a $10 copayment and not a $20 copayment. 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 $20 copayment for all other in-network Medicare-covered outpatient hospital services. You have been asked to pay a $20 copayment for each of the outpatient clinic visits. The outpatient clinic visits fall within the "Outpatient hospital services" benefit category. The record shows you were billed by an outpatient clinic.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 reduce the copayment forthe outpatient clinic visits provided from April 2, 2019 to December 30, 2019. Your complaint that your insurance contract is dishonest 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.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the SPECT test or the Part B injection provided on November 8, 2019. You asked the Plan to waive the cost share for the SPECT test and the Part B injection. You say that you were not told you would have to pay extra money so you could decide if you could afford these services. 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 $100 copayment for Medicare-covered nuclear medicine at a freestanding provider and 20% coinsurance for Medicare Part B-covered chemotherapy drugs and other Medicare Part B-covered drugs (including certain drugs that are used with nebulizers, insulin pumps, and IV infusion pumps). You have been asked to pay a $100 copayment for the SPECT test and $42.64 which is 20% of the allowed amount for the Part B injection. The allowed amount is $213.19. ($213.19 x 20% = $42.64). The SPECT test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Part B injection falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for a the SPECT test or the Part B injection provided on November 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three crowns (D2740), three core buildups, including any pins when required (D2950), four bone grafts at time of implant placements (D6104), and full mouth debridement (D4355).You asked the Plan to pre-approvethe crowns, core buildups, bone grafts, and full mouth debridement. You say that there is no historyof a cleaning and the last exam was done in 2014.The Plan denied your request. The Plan says crown, core buildup, bone graft are not covered services. The Plan also says that you received a comprehensive oral evaluation (D0150) on January 27, 2020 which exceeds the benefit limitations.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, crown (D2740), core buildup, including any pins when required (D2950), and bone graft at time of implant placement (D6104) are not among those covered under this benefit. The Plan contract clearly states that full mouth debridement (D4355) cannot be performed the same day or less than 1 calendar year after an evaluation (D0120, D0150). The record shows that you received a comprehensive oral evaluation (D0150) on January 27, 2020 and therefore your benefit limitations are now exceeded.Therefore, we decided that the Plan does not have to pre-approvethree crowns (D2740), three core buildups, including any pins when required (D2950), four bone grafts at time of implant placements (D6104), and full mouth debridement (D4355).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture with flexible base.You asked the Plan to pre-approve the maxillary partial denture. You say that you have had your current denture for 7 years. You also say that your dentist determined that your denture is very deteriorated, and you have a lot of discomfort from it.The Plan denied your request. The Plan says this service is not a covered benefit under your policy.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 pre-approve a maxillary partial denture with flexible base.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOneTouch Verio Flex System Kit.You asked the Plan to pre-approvethe non-preferred brand. You say that the blood glucose monitor will help the enrollee monitor sugar more closely. The Plan denied your request. The Plan says a non-preferred meter and test strips must be deemed medically necessary for the member by a healthcare provider.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no physician documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand have not been met.Therefore, we decided that the Plan doesnot have to pre-approveOneTouch Verio Flex System Kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom foot orthotics (L3020).
You asked the Plan to pre-approve foot orthotics. You say that you were diagnosed with plantar fasciitis which was corrected with orthotics previously. However, structural changes have occurred in your feet that need to be addressed. You also say that your podiatrist deemed that orthotics are critical to restore pain free movement and to alleviate abnormal foot mechanics. The Plan says that foot orthotics are not a covered benefit under your contractual policy for your condition.
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-approve custom foot orthotics (L3020).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. You say that this is medically necessary.The Plan denied your request. The Plan says that the patient has plateaued in therapy with minimal progress.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 indenying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued SNF services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility(SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for routine transportation.
You asked the Plan to pre-approve the additional mileage. You say that you have an appointment in Philadelphia with a Neurologist and you would like to have the transportation approved. The Plan denied your request. The Plan says the requested service is not covered under the plan benefits.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to 50 one-way trips to plan approved locations and each one-way trip must not exceed 60 miles. The records show that the mileage from the enrollee's home address to the requested neurologist office is 93.4 miles for each one-way trip, which exceeds the plan benefit. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Tempus Gene Panel testing provided on July 31, 2019.You asked the Plan to pay forthis testing. You say that this testing was medically necessary.The Plan denied your request. The Plan says this testing is not covered by Medicare.The Plan follows Medicare rules. The rules explicitly say that screening testsare not covered.The Plan contract states outpatient diagnostic testing may require prior authorization. The enrollee did not have prior authorization for this testing. The test at issue in this appealappears to have been requested for screening purposes. Medicare does not cover this test for screening purposes.Therefore, we decided that the Plan does not have to pay forTempus Gene Panel testing provided to the enrollee on July 31, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided on July 23, 2019 and August 13, 2019.You asked thePlan to waive the copayments forspecialist visits. You say that these were follow-up visits and 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 $45 copayment per specialist visit.You received specialist visits on July 23, 2019 and August 13, 2019. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay a $45 copayment per each visit. The total amount you owe is: $90. You have been asked to pay the total copayment amount of $90 for specialist visits. Specialist visits fall within the physician/practitioner services, including doctor's office visits 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 copayments forspecialist visits provided on July 23, 2019 and August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on September 16, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on September 16, 2019.