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

We decided that the Plan does not have to pre-approve an upper partial denture (D5213).
You asked the Plan to pre-approve the dental service. You say that you went on the plan website and could not find that denture and partials are not covered. You also say that partial dentures were covered last year in 2019 so you would assume they were still covered. The Plan denied your request. The Plan says the upper partial denture 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 upper partial denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on October 7, 2019 by the out of network provider.
You asked the Plan to pay for the dental service. You say that you have been seeing this dentist for 30 years. You say that the claims from this provider have always been paid. You also say that you were always told that dentists are not part of the doctors' network system. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says that services you receive out of network 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, dental services that you receive out of network are not covered. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on October 7, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fordental services (extraction of teeth) provided on November 12, 2019.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the services are not a covered benefit under the plan.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. Dental services are limited to services covered by Original Medicare: We cover non-routine dental care such as surgery of the jaw or related structures, setting fractures of the jaw orfacial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician. Furthermore, removal (extraction) or replacement of teeth are services that are notcovered by Medicare.Therefore, we decided that the Plan does not have to pay fordental services (extraction of teeth) provided on November 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral device or appliance used to reduce upper airway collapsibility to be provided by an OON provider.
You asked the Plan to pre-approve the oral device or appliance. You say that you previously called the Plan and were advised that you were in-network with the enrollee's Plan. The Plan denied your request. The Plan says this provider is a non-contracted provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received out-of-network. The Plan offers several contracted providers who specialize in dental sleep medicine. Therefore, we decided that the Plan does not have to pre-approve an oral device or appliance used to reduce upper airway collapsibility to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the orthotics purchased on November 13, 2019.
You asked the Plan to reimburse you for the orthotics. You say that you had a prescription and you were told you would be reimbursed 80%. The Plan denied your request. The Plan says the provider is not registered with Medicare. The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. The services at issue in this appeal were provided in a non-urgent, non-emergent situation. This provider does not participate in the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for the orthotics purchased on November 13, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided to the enrollee from
July 2, 2019 through July 19, 2019.
You asked the Plan to waive the copayment for SNF care. You say that your mother was in a skilled nursing
facility for 59.5 days and you feel as though your mother has satisfied the 60 day mandate for full coverage.
The Plan denied your request. The Plan says the claims were processed accordingly with the member's 2019
EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
According to the member's 2019 EOC, Days 1-20: You pay a $0 copay per day for Medicare-covered skilled
nursing facility care up to day 20. Days 21-100: You pay a $75 copay per day. You pay all costs for each day
after day 100. Per the members claim history the member was admitted for SNF services on "April 19, 2019 -
April 30, 2019 (12 days), April 19 through May 4, 2019, May 1, 2019 - May 4, 2019 (4 days) and July 2, 2019
- July 19, 2019, (18 days). This means that the enrollee has been asked to pay the correct amount based on the
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in
the Plan. Therefore, we decided that the Plan does not have to waive the copayment for SNF care provided to
the enrollee from July 2, 2019 through July 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on November 13, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that the laboratory services were provided during an annual wellness exam. 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 $10 copayment for laboratory tests. You received laboratory services on November 13, 2019. Laboratory services are not included in annual wellness visits. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory services provided on November 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair accessories.
You asked the Plan to pre-approve power wheelchair accessories. You say that the enrollee needs the accessories. The Plan denied your request. The Plan says the enrollee can weight shift and does not have edema in the lower legs.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. The file shows that the enrollee received the power wheelchair in 2019. The enrollee has not had a significant change in ability from when the new power wheelchair was approved. The features are not medically necessary for activities of daily living. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to youby an out-of-network provider on April 27, 2019, and November 19, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrolleesto 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 isnot a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. 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 forthe medical services provided to you by an out-of-network provider on April 27, 2019, and November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that this appointment was needed prior to surgery. The Plan denied your request. The Plan says there are in-network providers available for these service.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forknee orthosis (L1833) and sleeve (L2397) provided November 5, 2019.You asked the Plan to pay forthe orthoses. You say that you are requesting a review of the claim and reprocess for payment.The Plan denied your request. The Plan says this request exceeds the DME reasonable useful lifetime.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.The records show that L1833 (LT) and L2397 (LT) was provided on July 31, 2019 and L1833 (RT) and L2397 (RT) on July 30, 2019. Therefore,this is prior to the two years which Medicare determines is the reasonable useful lifetime for the equipment.Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met.Therefore, we decided that the Plan does not have to pay forknee orthosis (L1833) and sleeve (L2397) provided November 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the enrollee needs to check her glucose four times a day. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and related supplies are covered when the beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. We looked at the file and Medicare rules. The record does not show that the enrollee is insulin-treated with multiple daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chiropractic services provided on May 6, 2019 through September 9, 2019.You asked the Plan to waive the copayment for the chiropractic services. You say that these services should be covered without a copayment. The Plan denied your request. The Plan says the copayments for these services were 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 Chiropractic Services. You have been asked to pay $300 for the 30 chiropractic services.  The chiropractic services fall within the Chiropractic Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for chiropractic services provided on May 6, 2019 through September 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an UpWalker.
You asked the Plan to pre-approve the UpWalker. You say that you need an UpWalker because it is much better to use. It lifts you up versus having you lean over, which is bad for the back. The Plan denied your request. The Plan says the UpWalker is not covered in accordance with Medicare guidelines.
The Plan must follow Medicare rules. The rules say Medicare will only provide DME coverage if your doctors and DME suppliers are enrolled in Medicare. The item at issue in this appeal is sold as a cash pay product. The UpWalker website states that the current suppliers are not enrolled in Medicare. Therefore, we decided that the Plan does not have to pre-approve an UpWalker.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper partial denture (D5213) and the lower partial denture (D5214).
You asked the Plan to pre-approve the dental items. You say that authorization for partial dentures got denied. You say that you called the plan to change your coverage. You say that you were advised to appeal the decision. The Plan denied your request. The Plan says partial dentures are 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 requested dental items are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the upper partial denture (D5213) and the lower partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Contour Next Test Strips (A4253).
You asked the Plan to pre-approve Contour Next Test Strips (A4253). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says that Contour Next Test Strips are not preferred test strips for the Plan.
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, the plan has not provided any medical records. Without this information, we are unable to assess whether the continued used of the current test strips is medically necessary and appropriate to ensure continuity of care and adequate treatment of the enrollee's medical needs. The plan has not substantiated their denial. 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. Therefore, we decided that the Plan has to pre-approve Contour Next Test Strips (A4253).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lower extremity orthosis, not otherwise specified (L2999).
You asked the Plan to pre-approve the orthosis. You say that you are requesting approval of the flexible lumbarsacral support brace without rod support. This treatment is recommended to minimize the possibility of a fall. The Plan denied your request. The Plan says the requested item is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items that do not meet the definition of a brace are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve lower extremity orthosis, not otherwise specified (L2999).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on April 29, 2019 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that your provider could not deny any medical services that were essential for the enrollee's health treatment. You also say that your provider depends upon the hospital staff to verify eligibility and to obtain the proper authorization for in-network and out-of-network providers from the enrollee's insurance. The Plan denied your request. The Plan says the services were rendered by a non-network provider. The Plan also says the enrollee was referred by their non-participating nursing facility.
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 subsequent nursing facility care provided on April 29, 2019 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CT scan provided by on November 1, 2019.
You asked the Plan to waive the coinsurance for the CT scan. You say that you have not had to pay for this service in the past. 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 20% coinsurance up to a maximum of $75 per day for Medicare-covered diagnostic radiology services. You have been asked to pay $46.09 which is 20% of the allowed amount for the CT scan. The allowed amount is $230.45. ($230.45 x 20% = $46.09). The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the CT scan provided on November 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 12, 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 the services were not authorized by 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 lab services provided to the enrollee on September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the parenteral nutrition supplies provided for dates August 27, 2010 through September 2, 2019.
You asked the Plan to pay for the parenteral nutrition supplies. You say that the documentation including the order and the delivery ticket support that this claim should be paid. The Plan denied your request. The Plan says the documentation does not contain any valid proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when POD is included in the records The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid POD. There is no delivery confirmation which supports that these items were received by the enrollee. Therefore, we decided that the Plan does not have to pay for the parenteral nutrition supplies provided for dates August 27, 2010 through September 2, 2019.