Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the nasal application device provided on September 26, 2019.
You asked the Plan to waive the coinsurance for the nasal application device. You say that the claim should have been paid in full based on your contract. 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% of the total cost for Medicare-covered durable medical equipment. You have been asked to pay $21.17 which is 20% of the allowed amount for the nasal application device. The allowed amount is $105.84. ($105.84 x 20% = $21.17). The nasal application device falls within the "Durable medical equipment (DME) and related 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 nasal application device provided on September 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Decipher Prostate Cancer Assay rendered on June 7, 2019.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 not medically necessary.The Plan must follow Medicare rules. Medicare rules say that the Deciper Prostate Cancer Assay is covered when specificcriteria are met.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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the DECIPHER Prostate Cancer Assay is used to determine which patients are at high risk of recurrence after radical prostatectomy (RP) and may be closely followed rather than receive post-operative radiation therapy (XRT). The 2019 NCCN Guidelines state that molecular and biomarkers may be considered in patients with low and very low risk disease or intermediate disease with life expectancy greater than 10 years. The medical records provided do not support that this enrollee meets these criteria; therefore, the testing was not medically necessary.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 pay forthe Decipher Prostate Cancer Assay rendered on June 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe wheelchair anti-tipping device andbelt safety w/buckle, provided on October 23, 2019.You asked the Plan to pay forthe wheelchair anti-tipping device and belt safety w/buckle. You say that the Plan should pay this claim.The Plan denied your request. The Plan says the records submitted do not include a physician's order for the accessories.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts toobtain the physician orderfor the items at issue in this appeal. The record does not contain a valid order for the accessoriesprovided in this case. The physician order for the wheelchair did not include the accessories at issue. Therefore, we decided that the Plan does not have to pay forthe wheelchair anti-tipping device and belt safety w/buckle, provided on October 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on March 12, 2019.
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for DME and related supplies. You received DME on March 12, 2019. The allowed amount is $73.23 and 20% of that is $14.64. You have been asked to pay the total coinsurance amount of $14.64 for DME. DME falls within the DME and related 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 DME provided on March 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the services you received from December 2, 2019, to December 4, 2019.You asked the Plan to waive the cost share. You say that you should only be responsible for the $300 copayment.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 $10 copayment for each lab test. Review of the file showsthat you were provided outpatient services from December 2, 2019, to December 4, 2019. The services fall within the outpatient hospital services and Part B drugs benefit categories. 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 waivethe cost share for the services you received from December 2, 2019, to December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthoses and suspension sleeves provided on September 12, 2019.You asked the Plan to pay forthe knee orthoses (L1833) and suspension sleeves (L2397). You say that the Plan should pay this claim.The Plandenied your request. The Plan says there are no notes from the last appointments to say the enrollee had knee or joint pains.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not mention, or support medical necessity for, the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthoses (L1833) and suspension sleeves (L2397) have not been met.Therefore, we decided that the Plan does not have to pay forthe knee orthoses and suspension sleeves provided on September 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral evaluation (D0120), prophylaxis, adult
(D1110), intraoral - complete series of radiographic images (D0210), and resin-based composite - two surfaces,
posterior (tooth/quad: 5) (D2392) provided on August 23, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says the claim was processed accordingly with your
2019 EOC benefits.
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 claim records indicate that you received D1110 - prophylaxis, adult and D0120 - periodic oral evaluation
on February 07, 2019, which was six (6) months prior to the service being rendered on August 23, 2019. CPT
codes D0210 and D2392 are not listed services and therefore are not covered under your 2019 plan. Therefore,
we decided that the Plan does not have to pay for periodic oral evaluation (D0120), prophylaxis, adult (D1110),
intraoral - complete series of radiographic images (D0210), and resin-based composite - two surfaces, posterior
(tooth/quad: 5) (D2392) provided on August 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 2D oral or facial photographic image (D0350) provided on December 11, 2019.You asked the Plan to pay forthe dental service. You say that you chipped your tooth. You also say that they checked your coverage.The Plan denied your request. The Plan says the 2D oral or facial photographic image is not listed as a covered service.Medicare generally does not cover dental services. However, the Plan offers adental 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 2D oral or facial photographic imageisnot among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe 2D oral or facial photographic image (D0350) provided on December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe crown, resin-based composite, and core buildup, including any pins when required provided by an OON provider on October 8, 2019.You asked the Plan to pay forthe crown, resin-based composite, and core buildup, including any pins when required. You say that when you asked the Plan, they told you that you could see out-of-network providers with a referral from your main doctor. You also say that you did get approval from your doctor for these services.The Plan denied your request. The Plan says the rendering provider is not a part of the Plan's dental network. The Plan also says that prior authorization was not obtained.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 OON. The records show that a representative from this provider's office spoke with the Plan and was advised that you did not have any out-of-network benefits, and any exceptions would have to be made directly with the Plan.Therefore, we decided that the Plan does not have to pay forthe crown, resin-based composite, and core buildup, including any pins when required provided by an OON provider on October 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extractions (D7140) for teeth # 21, 22, 26, 27, and 28, a complete upper denture (D5120), an interim lower denture (D5130), and a reline for a complete upper denture (D5750).
You asked the Plan to pre-approve the dental services. You say that 3 plan representatives advised that the plan would cover your dentures because it was an emergency. You say that your bottom teeth were loose and had to be pulled. You say the same has to be done for your top teeth. You also say that you cannot eat anything without dentures. The Plan denied your request. The Plan says a complete denture, interim denture, and reline of an upper denture are not listed as covered services. The Plan also says that the requested extractions exceed the frequency limit.
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 dentures and denture reline are not among those covered under this benefit. Additionally, the record shows that you received the requested extractions on October 9, 2019. Therefore, we decided that the Plan does not have to pre-approve extractions (D7140) for teeth # 21, 22, 26, 27, and 28, a complete upper denture (D5120), an interim lower denture (D5130), and a reline for a complete upper denture (D5750).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic lumbar medical branch blocks.
You asked the Plan to pre-approve diagnostic lumbar medical branch blocks. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that lumbar sacral facet joint blocks are only 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 diagnostic lumbar medical branch blocks. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you have both neck and low back pain. Your neck pain is predominately axial and the low back pain radiates to your leg. The documentation does not support that you meet criteria for the requested diagnostic lumbar medical branch block. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of diagnostic lumbar medical branch blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve diagnostic lumbar medical branch blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 14,2020 by a non-participating 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 referring provider 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 January 14, 2020 by a non-participating provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zolpidem Tartrate.
You asked the Plan to pre-approve Zolpidem Tartrate. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered 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 are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zolpidem Tartrate.
Benefits for Zolpidem Tartrate may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental core buildup for tooth #12.
You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says the dental 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. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a dental core buildup for tooth #12.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided to the enrollee from August 18, 2019 through September 22, 2019.You asked the Plan to waive the copayment for the SNF services. You say that the enrollee went over his annual maximum out-of-pocket.The Plan denied your request. The Plan says that 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $160 copayment for each day for days 21 to 55 of SNF care. The enrollee has been asked to pay a $2,400 copayment for the SNF services. The enrollee was in a SNF for 35 days. Fifteen days of SNF services fall within days 21 to 55 of SNF care benefit category. 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.The documentation provided also indicates that the enrollee did not reach the annual out-of-pocket maximum of $5,500. Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided to the enrollee from August 18, 2019 through September 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you on September 26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim must be submitted first to the primary insurer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the services provided to you on September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on November 20, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the medical records do not support this service.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the orthosis. Our reviewer says that the enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a physical examination of the back. The documentation does not support that the spinal orthosis is ordered to reduce pain by restricting mobility of the trunk; or to facilitate healing following an injury to the spine or related soft tissues; or to facilitate healing following a surgical procedure on the spine or related soft tissue; or to otherwise support weak spinal muscles and/or a deformed spine. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CPAP and supplies provided on December 10, 2019 and January 10, 2020.You asked the Plan to waive the coinsurance forthe CPAP and supplies. You say that you should not be charged during the provider's grace period. The Plan denied your request. The Plan says the suppliers grace period was just for the mask.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 for Durable Medical Equipment and related supplies. You have been asked to pay 20% coinsurance for the CPAP supplies. the CPAP supplies falls within the Durable Medical Equipment and related 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 forthe CPAP and supplies provided on December10, 2019 and January 10, 2020