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

We decided that the Plan does not have to pay for physician's services provided on March 10, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior authorization was not obtained by the 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 did not pre-approve the physician's services.We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not haveto pay for physician's servicesprovidedon March 10, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forradiation therapy planning and administration received from a non-contracted provider on August 28, 2020.You asked the Plan to pay forradiation therapy planning and administration. You say that the requested services were medically necessary.The Plan denied your request. The Plan says that prior authorization for these services was notgranted.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. Medicare rules also say that PPO Plans must provide reimbursement for all Plan-covered medically necessary services received from non-contracted providers without prior authorization requirements.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 radiation therapy planning and administration. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found that the requested items/services are necessary based on the large tumor size and location on the scalp, otherwise requiring Mohs surgery that may not be feasible due to advanced age, and alow metastatic rate of the tumor.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiation therapy planning and administration have been met.Therefore, we decided that the Plan has to pay forradiation therapy planning and administration received from a non-contracted provider on August 28, 2020.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 toopen 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 unspecified preventative procedure (D1999) provided on August 27, 2020.
You asked the Plan to pay for the unspecified preventative procedure. You say that you believed this dentist was in-network. The Plan denied your request. The Plan says this service is not covered under your 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 unspecified preventative procedure (D1999) provided on August 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on August 13, 2020
You asked the Plan to pay for the periodontal maintenance. You say that this service is necessary for your health and medical conditions. 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 periodontal maintenance provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe EGD provided on September 8, 2020.You asked the Plan to waive the copayment forthe EGD. You say that out-of-pocket costs were waived by the Plan through September 30, 2020. 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 $370 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You havebeen asked to pay a $370 copayment for the EGD. The EGD falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows copayments, coinsurance and deductibles for outpatient surgery are not waived. The EGD is considered outpatient surgery.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 EGD provided on September 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fifth restaging positron emission tomography (PET) scan.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare covers up to three PET scans for subsequent treatment strategy. We looked at the file and Medicare rules. The requested services are a fifth subsequent PET scan. Medicare covers up to three PET scans for subsequent treatment strategy. There is no local coverage determination that allows more than three PET scans in your state. 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 a fifth restaging positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mandibular partial denture - resin base (including,
retentive/clasping materials, rests, and teeth) (D5212) and maxillary partial denture - resin base (including,
retentive/clasping materials, rests, and teeth) (D5211).
You asked the Plan to pre-approve the dental services. You say that you need the dentures to be adjusted in
order for your dentures to fit better. The Plan denied your request. The Plan says you need the dentures to be
adjusted in order for your dentures to fit better.
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.
Review of the file shows that you exhausted your benefit frequency limit because you received these services
on October 12, 2020, which is within the five years outlined in your EOC. Your 2021 EOC states complete
dentures (upper and lower) - one upper complete and one lower complete denture every five years, including
routine post-delivery care) or partial dentures (upper and lower) - one upper and/or one lower partial denture
every five years, including routine post-delivery care). Therefore, we decided that the Plan does not have to
pre-approve mandibular partial denture - resin base (including, retentive/clasping materials, rests, and teeth)
(D5212) and maxillary partial denture - resin base (including, retentive/clasping materials, rests, and teeth)
(D5211).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided March 10, 2020, to March 11, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that the care provided was medically necessary and reasonable.The Plan denied your request. The Plan says the inpatient care was not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the patient is an 84-year-oldfemale who presented with right forehead pain. She was brought to the emergency department after a ground level fall. She was treated with local wound care, fluids, and computed tomography (CT)scan was negative. At the time of admission, however, based on the patient's stability and low severity of her condition, it was not expected that she would require at least a 2-midnight stay in the hospital.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided March 10, 2020, to March 11, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a breast prosthesis (L8031) for the enrollee.
You asked the Plan to pre-approve the prosthesis. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a breast prosthesis coded with L8031 is not covered. The requested prosthesis is coded with L8031. Based on this information, we decided that Medicare rules for coverage of the prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a breast prosthesis (L8031) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveViibryd 40mg tablets.You asked the Plan to pre-approveViibryd. You say that Viibryd is medically necessary.The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.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 arenot among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveViibryd 40mg tablets.Benefits for Viibrydmay 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: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from June 1, 2020, through August 20, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 physician's services. 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 from June 1, 2020, through August 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on
April 22, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered
benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on April 22, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care provided on September 4, 2020, through September 6, 2020.You asked the Plan to waive the copayment forinpatient hospital care. You say that the services should be covered.The Plan denied your request. The Plan says the cost share was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment per day for days one to five for inpatient hospital care. You have been asked to paya $350 copayment per day for days one to five for inpatient hospital care. This service falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan ($350 x 2= $700). 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 forinpatient hospital care provided on September 4, 2020, through September 6, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe telemedicine visit provided on April 27, 2020.You asked the Plan to waive the copayment forthe telemedicine visit. You say that this was not a preventative visit.The Plan denied your request. The Plan says you were charged the coinsurance 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 $10 copayment for Physician Services. You have been asked to pay a $10 copayment for the telemedicine visit. The telemedicine visit falls within the Physician 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 forthe telemedicine visit provided on April 27, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met at a different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found based on the medical records provided the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the
medical records provided It is not clear you would be able to fully benefit and/or participate in an IRF level of
care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist telehealth visit (99213)
provided June 19, 2020.
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that your copayment
should be waived. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10
copayment for each specialist visit for Medicare-covered benefits.
You have been asked to pay a $10 copayment for the specialist telehealth visit. Specialist telehealth visits fall
within the Physician/Practitioner services, including doctor's office visits benefit category. There is no
evidence that a copayment waiver applied for the date of service at issue. 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 the specialist telehealth visit (99213) provided June 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forexcision, malignant lesion (11602) intermediate wound repair (12032) level IV surgical pathology (88305) provided on February 6, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe excision and repair services. You say that you feel that this should be paid because you were not aware that the plan became effective 02/01/2020. This was prescheduled prior to coming to the plan.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network providerwith the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.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 forexcision, malignant lesion (11602) intermediate wound repair (12032) level IV surgical pathology (88305) provided on February 6, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemethadone.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not covered.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-approvemethadone.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the knee x-ray provided on October 20, 2020.
You asked the Plan to waive the copayment for the knee x-ray. You say that this x-ray should have been a part of your surgical follow-up visit that was cancelled one year ago. 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 $10 copayment per day for Medicare-covered x-rays. You will only pay one copayment per day even if multiple x-rays are performed. You have been asked to pay a $10 copayment for the knee x-ray. The knee x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a part of a follow-up to a surgical procedure.
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 the knee x-ray provided on October 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of X-rays (D0210) and unspecified preventative procedure (D1999) provided on September 23, 2020.
You asked the Plan to pay for the intraoral - complete series of X-rays and unspecified preventative procedure. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says these services are not covered under your 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 intraoral - complete series of X-rays (D0210) and unspecified preventative procedure (D1999) provided on September 23, 2020.