Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on November 1, 2019 to November 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physical therapy services. You say that this claim was denied in error. Please reprocess this claim for immediate payments. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to 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 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 physical therapy services provided on November 1, 2019 to November 14, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental surgery procedure, removal of residual tooth roots, anesthesia for intraoral procedures, and rhythm ECG tracing provided on February 5, 2019.
You asked the Plan to pay for the dental surgery procedure, removal of residual tooth roots, anesthesia for intraoral procedures, and rhythm ECG tracing. You say that the Plan told you that 50% of the charges for claims related to your accident would be covered. The Plan denied your request. The Plan says this procedure was not submitted for prior authorization by your provider. The Plan also says that you do not have a dental rider that provides additional dental services.
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. The Plan contract says that 50% of the total cost for Medicare-covered services provided out-of-network would be covered by the Plan. The record shows that you are not enrolled in the dental rider that provides supplemental preventive and comprehensive dental services. Therefore, we decided that the Plan does not have to pay for the dental surgery procedure, removal of residual tooth roots, anesthesia for intraoral procedures, and rhythm ECG tracing provided on February 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthotic device (L1971) provided January 22, 2020.
You asked the Plan to pay for the orthotic device. You say that the item was medically necessary. The Plan denied your request. The Plan says the provided documents do not support the item billed.
The Plan must follow Medicare rules. Medicare rules say that for any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered. We looked at the file and Medicare rules. The provided records are limited to the physician order and the proof of delivery. The plan did not receive requested supporting medical documentation to support that the item was medically necessary for the enrollee. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pay for an orthotic device (L1971) provided January 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto for the enrollee.
You asked the Plan to pre-approve this drug. 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-approve Xarelto for the enrollee.
Benefits for this drug 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 pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on January 28, 2020.
You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that when you got this insurance all you knew was that you were given $1,500 yearly. You also say that nothing was explained to you and you were not aware of what was covered and what was not covered. The Plan denied your request. The Plan says these services exceed the frequency limitations in the benefit plan.
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, comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) on January 8, 2020 and your comprehensive oral evaluation and panoramic x-ray benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator with rental (E1390, E1392) provided on January 26, 2020.
You asked the Plan to pay for the oxygen concentrator. You say that the items were medically necessary. The Plan denied your request. The Plan says the enrollee has no out-of-network benefits. The services were available from network providers.
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 oxygen concentrator with rental (E1390, E1392) provided on January 26, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on January 1, 2020.
You asked the Plan to waive the copayment for an ER visit. You say that you were not in the right state of mind to determine if you needed emergency services. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 copayment for emergency care. You have been asked to pay a $120 copayment for an ER visit. An ER visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ER visit provided on January 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve holistic treatment.
You asked the Plan to pre-approve holistic treatment. 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 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 holistic treatment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you were recently diagnosed with metastatic breast cancer. You underwent bilateral mastectomies. You are refusing additional therapy and want to continue care with your natural medicine provider(s). The documentation does not support that the requested service is medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of holistic treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve holistic treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397)
provided December 20, 2019.
You asked the Plan to pay for the orthoses. You say that the records should support the necessity of the service
in dispute. The Plan denied your request. The Plan says there is no evidence of an established relationship
between the enrollee and the ordering physician, there was no claims submitted for an evaluation and
management service and there is no evidence of a prior telehealth service with the ordering physician as
required per CMS guidelines.
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 non-covered visit are
likewise non-covered. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833)
and suspension sleeve (L2397) provided December 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 4, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 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 December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment deluxe frames (V2020) and progressive lenses (V2781) purchased December 13, 2019 from an out-of-network provider.
You asked the Plan to waive the copayment the vision services. You say that you were not aware that this provider was not in-network. You would not have used them had you known. They did not find out they were out-of-network until after ordering and paying the glasses. The Plan denied your request. The Plan says the claim was processed correctly and the correct out of network cost share was applied.
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 45% coinsurance when you get these services out-of-network. You have been asked to pay $228.60 for the vision services. the vision services fall within the vision care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment deluxe frames (V2020) and progressive lenses (V2781) purchased December 13, 2019 from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve the requested device. You say that it is too difficult to travel with your current machine. The Plan denied your request. The Plan says duplicate services are considered not reasonable or medically necessary.
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 file shows that you have a portable oxygen concentrator. Your current device serves the same purpose as the requested device. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral device/appliance provided by the non-par provider on September 20, 2018.
You asked the Plan to pay for the oral device/appliance. You say that the dentist delayed filing the claim. The Plan denied your request. The Plan says the claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the oral device/appliance was not filed until February 17, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the oral device/appliance provided by the non-par provider on September 20, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says that they did not
receive documentation supporting the medical necessity for a step therapy exception.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Euflexxa. Our reviewer says that
Euflexxa is not medically reasonable and necessary for the enrollee in this case. The provided medical records
do not indicate that the enrollee has tried and failed the Plan's required drugs or that they would likely be less
effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's
condition does not meet step therapy criteria for Euflexxa.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have
to pre-approve Euflexxa for the enrollee.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the AAA ultrasound provided on December 19, 2019.
You asked the Plan to waive the copayment for the AAA ultrasound. You say that you were told that the
ultrasound would be covered as a part of your wellness visit. You say you are on a fixed income and was not
expecting this bill. The Plan denied your request. The Plan says that 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. Your
contract with the Plan says that there is no coinsurance, copayment, or deductible for members eligible for a
preventive abdominal aortic screening.
The Plan says you must pay a $100 copayment for the AAA ultrasound. Based on the Plan contract, however,
you cannot be asked to pay more than $0 for a preventive abdominal aortic ultrasound screening. The record
shows you were billed for code 76706 which is an ultrasound screening study for abdominal aortic aneurysm
(AAA). Therefore, we decided that the Plan has to waive the copayment for the AAA ultrasound provided by
on December 19, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ENTYVIO for the enrollee.
You asked the Plan to pre-approve ENTYVIO. The Plan denied your request. The Plan says that they did not
receive documentation supporting the medical necessity for a step therapy exception.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 ENTYVIO. Our reviewer says that
ENTYVIO is not medically reasonable and necessary for the enrollee in this case. The provided medical
records do not indicate that the enrollee has tried and failed the Plan's required drugs or that they would likely
be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the
enrollee's condition does not meet step therapy criteria for ENTYVIO. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of ENTYVIO have not been met. Therefore, we decided that the Plan does not
have to pre-approve ENTYVIO for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from
February 12, 2020 to February 17, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you thought that you
would only owe $275 for the entire stay. 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 $150
copayment per day for days 1-5 for inpatient hospital care.
You had an inpatient hospital stay from February 12, 2020 to February 17, 2020. Therefore, you are
responsible to pay a $150 copayment for days 1-5 (February 12, 2020 to February 16, 2020). $150 (copayment)
x 5 (inpatient days) = $750.
You have been asked to pay the total copayment amount of $750 for an inpatient hospital stay. An inpatient
hospital stay 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. 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 inpatient hospital stay provided from February 12, 2020 to February 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eye exam(92004) and the eye refraction (92015) provided on November 19, 2019.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services.Therefore, we decided that the Plan does not have to pay forthe eye exam (92004) and the eye refraction (92015) provided on November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran Annual Wellness Visit provided on December 18, 2019.You asked the Plan to pay forAnnual Wellness Visit. You say that you did not know that this visit was an Annual Wellness Visit, and the doctor gave you an examination that was like a physical.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the Annual Wellness Visit is only covered once every 12 months and you previously had an Annual Wellness Visit on July 1, 2019.The Plan must follow Medicare rules. Medicare rules say that an Annual Wellness Visit is not covered by Medicare if another Annual Wellness Visit had been performed within the previous 12 months.We looked at the file and Medicare rules. You received an Annual Wellness Visit on July 1, 2019, therefore 12 months had not passed before this Annual Wellness Visit was provided. Based on this information, we decided that Medicare rules for coverage of Annual Wellness Visit have not been met.Therefore, we decided that the Plan does not have to pay foran Annual Wellness Visit provided on December 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRestasis Emu 0.05%.You asked the Plan to pre-approveRestasis Emu. 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-approveRestasis Emu 0.05%.Benefits for Restasis Emumay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.