Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Botulinum Toxin (Botox).
You asked the Plan to pre-approve Botox. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Botox is covered for certain indications. 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 Botox. Our reviewer says that the documentation supports that the requested Botox is medically reasonable and necessary. Our physician reviewer found you have a history of chronic migraines. You have 15 migraine days per month. You have tried and failed two other classes of migraine medications. Your MRI is compatible with chronic migraines. Therefore, you meet criteria for the requested Botox. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have been met. Therefore, we decided that the Plan has to pre-approve Botulinum Toxin (Botox).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the crown replacement you received on December 2, 2020.
You asked the Plan to waive the coinsurance for the crown replacement. You say that you should not have to pay this coinsurance because crown repair is covered at $0. You say it is splitting hairs to charge for a replacement crown. You also say that you already had a crown on that tooth but it came off due to decay underneath. The Plan denied your request. The Plan says because you received a crown replacement and not repair, this coinsurance was charged 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 50% coinsurance for major restorative services including crowns, onlays, and associated substructures. You have been asked to pay 50% coinsurance for the crown replacement. The crown replacement falls within the major restorative services including crowns, onlays, and associated substructures 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 crown replacement you received on December 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on May 18, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels except the basic lipid panel.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Without a lab order, it cannot be determined whether this testing was performed for covered purposes. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on May 18, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay the out of network rate for the oral exam, cleaning, initial periapical x-ray,
and the application of fluoride varnish. We decided that the Plan does not have to pay the out of network rate
for 2 additional periapical x-rays, and the PPE.
You asked the Plan to pay the out of network rate for the oral exam, cleaning, initial periapical x-ray, and the
application of fluoride varnish. You say that you have been seeing this dentist for many years. You say that the
services should be covered at the in-network rate. The Plan denied your request. The Plan says that the provider
in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services that
you receive from a provider who has opted out of Medicare.
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 dental
services when the services are medically necessary and reasonable.
We decided that the Plan has to pay the out of network rate for the oral exam, cleaning, initial periapical
x-ray, and the application of fluoride varnish.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the oral exam, cleaning, initial periapical x-ray, and the application of fluoride varnish have been
met. Therefore, we decided that the Plan has to pay the out of network rate for the oral exam, cleaning, initial
periapical x-ray, and the application of fluoride varnish. The out of network cost share amounts still apply.
We also decided that the Plan does not have to pay the out of network rate for 2 additional periapical xrays,
and the PPE.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the 2 additionally periapical x-rays and PPE have been met. The Evidence of Coverage says that 1
periapical x-ray per calendar year. The record shows that the frequency limit has been exceeded with the
approval of the initial periapical that you received on this date of service. Additionally, PPE is not among the
services that are covered under this benefit. Therefore, we decided that the Plan does not have to pay the out of
network rate for 2 additional periapical x-rays, and the PPE.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided by an out of network (OON) provider.

You asked the Plan to pay for an office visit. You say that you would like to have this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider. The Plan says that the referring provider is also out-of-network.

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 had network providers available who could have provided 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 an office visit provided by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided to the enrollee.

You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 had network providers available who could have provided 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 outpatient services provided to the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve blepharoplasty for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that medical need has not been shown.
The Plan must follow Medicare rules. Medicare rules say that photographs are required to support upper eyelid surgery as 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The surgical treatment of the patient's dermatochalasis does not meet criteria for coverage because there are no photographs in the record to support the need for surgery. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for coverage. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve blepharoplasty for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two extractions provided on November 13, 2020.
You asked the Plan to pay for the extractions. You say that you cannot pay this bill. The Plan denied your request. The Plan says this service is not 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 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 two extractions provided on November 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. You say that this lab work was requested by a referring provider. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.

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 had network providers available who could have provided 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 lab work provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the addition of a tooth to an existing partial denture (D5650).

You asked the Plan to pay for the dental service. You say that you told the provider that you do not have money. You also say that if the service costs money, then you would not have the service. The Plan denied your request. The Plan says the addition of a tooth to an existing partial denture is not listed as a covered service. The Plan also says that any services not listed in the dental benefit chart are not 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 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 addition of a tooth to an existing partial denture (D5650).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the local anesthesia in conjunction with operative or surgical procedures (D9215).

You asked the Plan to pay for the local anesthesia. You say that after the services were provided, you were told that the Plan only covers nitrous oxide for dental procedures. You are appalled by this because it is a drug and the Novocaine, which was denied, is a simple local anesthetic. The Plan denied your request. The Plan says the local anesthetic is not covered by Medicare or listed as a covered item/service in the Plan's supplemental dental benefit.

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 local anesthesia in conjunction with operative or surgical procedures (D9215).

Your complaint about the services the Plan is able to cover or not cover 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care services coded 99308.

You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed exceed the MUE for this date of service.

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 code 99308 is 1. You billed 2 units of this code, exceeding the MUE. Review of the file shows that this code was previously billed and paid for this date of service. Based on this information, we decided that Medicare rules for coverage of the subsequent nursing facility care services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care services coded 99308.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy.

You asked the Plan to pay for the endodontic therapy. You say that you believe that this service should be covered at 70% coinsurance. The Plan denied your request. The Plan says this service is not 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 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 endodontic therapy.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on October 23, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges you were told that the tests were not needed. 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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided on October 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473).
You asked the Plan to pre-approve the removal of torus mandibularis. You say that this is a necessary service and should be covered. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental benefit.
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 the removal of torus mandibularis (D7473).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Clindamycin phosphate injection services coded S0070.

You asked the Plan to pay for the Clindamycin phosphate injection 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 not payable.

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 S0077 is injection, Clindamycin phosphate, 300 mg.

We find that CPT code S0077 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the Clindamycin phosphate injection services have not been met. Therefore, we decided that the Plan does not have to pay for the Clindamycin phosphate injection services coded S0070.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on April 18, 2019 from a non-plan vendor.
You asked the Plan to pay for these hearing aids. You say that you were told hearing aids were covered by the Plan. The Plan denied your request. The Plan says you did not purchase your hearing aids from the providers required by the Plan.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are purchased from designated provided. You did not follow your 2019 Plan rules when you purchased these hearing aids. Therefore, we decided that the Plan does not have to pay for hearing aids purchased on April 18, 2019 from your provider.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve 12 additional physical therapy (PT) visits (97164).
You asked the Plan to pre-approve the additional PT visits. You say that you are requesting an appeal for additional physical therapy visits for 1 time a week for 10 weeks. The Plan denied your request. The Plan says that additional pt visits is not medically necessary and the enrollee does not meet the Medicare criteria for coverage.
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 the additional PT visits. Our reviewer says that the requested item/service is considered medically necessary in this case. Our physician reviewer found the case file contains a Low Back Discharge note that documents that the enrollee had continued functional deficits and pain but was being discharged due to a lack of insurance benefits. A Balance Initial Evaluation is dated 2/22/21. The enrollee reported increasing difficulty with gait and balance. The enrollee had a shuffling, antalgic gait. The enrollee had limitations in strength, balance, and function. The enrollee's rehab potential was noted to be "Good." The records do demonstrate that the 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 for physical therapy and occupational therapy, by or under the supervision of a therapist.
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 additional PT visits have been met. Therefore, we decided that the Plan has
to pre-approve 12 additional physical therapy (PT) visits (97164).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the cataract surgery you had on October 28, 2020.
You asked the Plan to waive the cost share. The Plan denied your request. The Plan says you are responsible for the cost share.
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 $750 deductible out-of-pocket before the Plan will pay its share for your covered medical services Your contract with the Plan also says that you must pay a $125 copayment after the deductible is met for each outpatient surgery. Review of the file show that you had cataract surgery on October 28, 2020. The records show that your deductible was not met at the time the surgery was provided. You have been asked to pay $685.18 to meet your deductible. After the deductible was met, you have been asked to pay a $125 copayment for the surgery. The surgery falls within the outpatient surgery 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 the cataract surgery you had on October 28, 2020.