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

We decided that the Plan does not have to pay for the 5 additional surgical extractions (D7140), and the alveoloplasty not in conjunction with extractions (D7320) provided from September 6, 2019 to October 2, 2019.
You asked the Plan to pay for the 5 additional extractions, and the alveoloplasty not in conjunction with extractions. You say that you would like an exception for the balance of $750 be applied to your dental bill since you will never use the dental coverage again. The Plan denied your request. The Plan says the frequency limit for extractions has been exceeded. The Plan also says that alveoloplasty not in conjunction with extractions is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit for extractions has been exhausted. The record shows that the Plan paid for 2 extractions that you received on September 6, 2019. Additionally, alveloplasty not in conjunction with extractions is not a covered service. Therefore, we decided that the Plan does not have to pay for the 5 additional surgical extractions (D7140), and the alveoloplasty not in conjunction with extractions (D7320) provided from September 6, 2019 to October 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomputed tomography (CT) of the chest (71260).You asked the Plan to pre-approvethe CT scan. You say that the CT scan is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 the CT scan. Our reviewer says that a CT scan of the chest is not medically necessary. Our physician reviewer found the records show a finding of sinusitis. The pulmonary exam is within normal limits.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvecomputed tomography (CT) of the chest (71260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549 and non-elastic binders for extremities.
You asked the Plan to pre-approve these items. You say that you need these items for your lymphedema. The Plan denied your request. The Plan says that these items are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549 and non-elastic binders for extremities.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hip x-ray rendered on June 5, 2019.Youasked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not separately payable.The Plan must follow Medicare rules. Medicare rules say that modifier -26 must be billed for separate payment of the PC.We looked at the file and Medicare rules. The claim for procedure code 73502 was not billed with the required -26 modifier to allow for separate payment of the PC. 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 forthe hip x-ray rendered on June 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says the enrollee has reached the 100-day benefit limit. Therefore, coverage criteria has not
been met.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that the enrollee received 100 days of SNF care during the benefit period from August 7, 2019
to January 26, 2020. The Plan has covered 100 days of SNF care.
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided
that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extraction provided on September 10, 2019.You asked the Plan to pay forthe extraction. You say that the oral surgeon conducted the procedure at the hospital rather than his office. You say that the hospital was necessary for your safety.The Plan denied your request. The Plan says this is not a covered benefit.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 forthe extraction provided on September 10, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on
June 13, 2019.
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that you were advised by a
Plan representative that the charges would be paid in full. The Plan denied your request. The Plan says there is
no record of the Plan receiving a call from you regarding your dental benefits prior to the services being
rendered. The Plan also says that this provider is out-of-network and the correct cost share has been applied to
your claim.
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 contract clearly states that you are
responsible for 100% of all charges that exceed the maximum allowable benefit per service. The contract also
states that you may pay more if you choose to go to an out-of-network dentist. Therefore, we decided that the
Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on June 13, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repetitive Transcranial Magnetic Stimulation (rTMS).
You asked the Plan to pre-approve the rTMS. You say that the treatment is medically necessary. The Plan denied your request. The Plan says coverage rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the rTMS. Our reviewer says that coverage criteria has not been met. Our physician reviewer found there is no mention of this enrollee having undergone psychotherapy or a referral for electroconvulsive therapy. The record does not show that the enrollee has trialed several different medications. There must be a documented failure of standard treatments before rTMS can be indicated. 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 rTMS have not been met. Therefore, we decided that the Plan does not have to pre-approve Repetitive Transcranial Magnetic Stimulation (rTMS).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (S9328) provided from August 21, 2019 to August 28, 2019.You asked the Plan to pay forhome infusion therapy. You say that this is a valid code.The Plan denied your request. The Plan says this code is not valid for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy (S9328) provided from August 21, 2019 to August 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) and a wrist-hand orthosis (L3916) provided to the enrollee on August 14, 2019.
You asked the Plan to pay for the 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 for a knee orthosis with suspension sleeve (L1851, L2397) and a wrist-hand orthosis (L3916) provided to the enrollee on August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on August 22, 2019.
You asked the Plan to waive the copayment for primary care visit. You say that this doctor is your primary care provider, so this charge is incorrect. 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 $20 copayment for primary care office visit. You have been asked to pay $20 copayment for primary care visit. primary care visit falls 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 copayment for an office visit provided on August 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 3, 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 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 October 3, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approvecontinued acute inpatient level of care.You asked the Plan to pre-approvecontinued acute inpatient level of care. You say that the requested continuation of acute inpatient hospital care is medically necessary.The Plan denied your request. The Plan says that the requested continuation of acute inpatient hospital care is not medically necessary.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. Specifically, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. The plan did not provide sufficient medical records in order to determine if the enrollee meets Medicare criteria for the inpatient hospital services received from December 27, 2019 to January 27, 2020.Therefore, we decided that the Plan has to pre-approvecontinued acute inpatient level of care.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy and first intraoral periapical x-ray provided on July 15, 2019 and August 14, 2019.
You asked the Plan to pay for the endodontic therapy and first intraoral periapical x-ray. You say that you were clear that you wanted to be made aware of your share of the payments before any procedure was rendered. You also say that you need more root canals and crowns, but you have no money to pay for them. The Plan denied your request. The Plan says endodontic therapy is not covered under your plan. The Plan also says that the first intraoral periapical x-ray exceeds the maximum allowed per period.
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, endodontic therapy is not covered under this benefit. The contract also clearly says that intraoral x-rays are limited to two procedures per plan year. The record shows that you received one intraoral periapical x-ray on March 5, 2019 and a second intraoral periapical x-ray on March 7, 2019 and your intraoral x-rays benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the endodontic therapy and first intraoral periapical x-ray provided on July 15, 2019 and August 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cup holder for the enrollee.
You asked the Plan to pre-approve a cup holder. The Plan denied your request. The Plan says that a cup holder is a convenience item.
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 cup holder for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 17, 2019 to May 28, 2019 by the out of network provider.
You asked the Plan to pay for podiatry services and X-Ray examination. You say that your primary care provider referred you to see this doctor for treatment. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the referring physician is also out-of-network with 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 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 May 17, 2019 to May 28, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 13, 2019 by out of network provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-participating provider without 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 forthe medical services provided on September 13, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Praluent pen for the enrollee.You asked the Plan to pre-approvethe Praluent pen. The Plan denied your request. The Plan says that this is not covered under 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-approvethe Praluent pen for the enrollee.Benefits for the Praluent penmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the physician's services provided by on August 1, 2019 and August 13, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the services were not prior authorized.
The Plan must follow Medicare rules. Medicare rules say that a contract provider is an agent of the plan. MA organizations have a responsibility to ensure that contracting physicians and providers know whether specific items and services are covered in the MA plan in which their patients are enrolled. We looked at the file and Medicare rules. The provider at issue in this appeal is a contracted, in-network provider with the Plan. Per Medicare guidelines, if a network physician furnishes a service to a MA beneficiary for a plan-covered service without following the plan's internal procedures (such as obtaining the appropriate plan pre-authorization), then the beneficiary should not be penalized to the extent the physician did not follow plan rules. Therefore, we decided that the Plan has to pay for physician's services provided on August 1, 2019 and August 13, 2019.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not have to pay forthe eye exam provided on August 30, 2019.You asked the Plan to pay forthe eye exam. The Plan denied your request. The Plan says this service is limited to one exam per year.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 one eye exam every year.We looked at the file and the Plan's rules. The file indicates the plan covered an eye exam on May 22, 2019. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met.Therefore, we decided that the Plan does not have to pay forthe eye exam provided on August 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on December 31, 2018.
You asked the Plan to reimburse you for the hearing aids. You say that you are on a fixed income and you have not been able to meet the monthly payments for the hearing aids. The Plan denied your request. The Plan says the maximum hearing aid benefit has been exhausted.
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 every 2 years. We looked at the file and the Plan's rules. The file shows that you received a reimbursement check of $1,000 on February 8, 2019 for hearing aids purchased on March 29, 2018. The file shows that the maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on December 31, 2018.