Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99306) provided on February 3, 2020.You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary.The Plan denied your request. The Plan says these out-of-network services were not emergent or pre-authorized.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 services at issue in this appeal. The Plan did not pre-approve the service 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 the nursing facility care (99306) provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles vaccine (90750) and administration (90471)
provided on February 26, 2020.
You asked the Plan to pay for a shingles vaccine and administration. You say that this was medically necessary
and your doctor recommended it. The Plan denied your request. The Plan says this vaccine is covered only
under Medicare Part D.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine
and administration. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine
and administration. Therefore, we decided that the Plan does not have to pay for a shingles vaccine (90750) and
administration (90471) provided on February 26, 2020.
Benefits for a shingles vaccine and administration 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 resin based composite - one surface, posterior teeth 5, 20, 21,
28, 29 (D2391) provided Resin-based composite - one surface, anterior, teeth 7 (D2330) February 11, 2020.
You asked the Plan to pay for the dental services. You say that you request for payment for dental work you
needed. You had bad cavities with many hurting teeth and needed fillings. You live off of $1,000 a month and
cannot afford a bill like this. The Plan denied your request. The Plan says the request for additional restorations
exceeds the benefit limitation.
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 health plan coverage is
limited to 2 restorations per calendar year. The records show that the plan had already approved payment for 2
restorations (tooth #6 from this same date service and tooth #15 from date of service February 4, 2020.
Therefore this benefit is exhausted.
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 resin
based composite - one surface, posterior teeth 5, 20, 21, 28, 29 (D2391) provided Resin-based composite - one
surface, anterior, teeth 7 (D2330) February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on March 6, 2020.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 diagnostic radiology services provided on March 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prophylaxis and topical application of fluoride varnish provided on November 14, 2019 by an OON provider.You asked the Plan to pay forthe prophylaxis and topical application of fluoride varnish. You say that you called and verified that this provider was in-network with your plan. You also say that this provider is listed on the Plan's website as an in-network provider.The Plan denied your request. The Plan says the treating provider was out-of-network with the Plan on this date of service. The Plan also says that services are not a covered benefit when rendered by a dentist who does not participate with the dental 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, the requested items or services are not covered when they are received OON. The records show that this provider became active within the Plan's network on December 1, 2019, and the participation date cannot be back dated.Therefore, we decided that the Plan does not have to pay forthe prophylaxis and topical application of fluoride varnish provided on November 14, 2019 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation services provided on April 22, 2020. You asked the Plan to pay for the transportation services. You say that you were transported to a doctor's office by wheelchair van. The Plan denied your request. The Plan says no authorization was obtained prior to the services being rendered. The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pay for are wheelchair van transport services. You did not receive prior authorization. Therefore, we decided that the Plan does not have to pay for the transportation services provided on April 22, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the consultation, cone beam CT capture and endodontic therapy
provided on January 8, 2020.
You asked the Plan to pay for the consultation, cone beam CT capture and endodontic therapy. You say that
you thought you would be covered in-network if you were referred by an in-network doctor. The Plan denied
your request. The Plan says that out-of-network dental services are not a covered benefit.
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. The Plan did not provide a copy of the 2020 Evidence of Coverage. We asked
for this document, but it was not provided to us. Without this information we cannot determine that the Plan's
coverage rules support the denial of payment in this case, or that the enrollee has been adequately notified of
the Plan's coverage rules and benefits. This means that the Plan has not substantiated their denial of payment in
this case. Therefore, we decided that the Plan has to pay for the consultation, cone beam CT capture and
endodontic therapy provided on January 8, 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 to open the case again, we will
send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) care.
You asked the Plan to pre-approve the SNF services. You say that the services are medically necessary. The
Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled
nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of
service criteria for an inpatient basis in a skilled nursing facility setting.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve Skilled Nursing Facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature.
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that you need a power seat
elevation feature to maintain your mobility. The Plan denied your request. The Plan says a power seat elevation
feature is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
A power seat elevation feature does not serve a purpose that is primarily medical in nature. This feature is not
covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation
feature.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia (J0897). You say that you want the enrollee treated with this drug.
The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or
intolerance to zoledronic acid.
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 Prolia (J0897). Our reviewer says that
criteria for this drug has not been met. Our physician reviewer found this appeal considers the request for Prolia
for the treatment of osteoporosis. Submitted documentation and Medicare guidelines were considered. Step
therapy, as outlined by the plan, requires a history of osteoporosis-related fracture or have documented failure
or contraindication to zoledronic acid. Review of the submitted documentation does not support either of these
criteria were met. Without the support of the documentation, Prolia is not approved as step criteria is not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia (J0897) have not been met. Therefore, we decided that the Plan does not
have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702).You asked the Plan to pre-approve the orthosis. You say that you are requesting a GAP exception and prior authorization. This is an orthotic device not a prosthetic device. It is meant for patients with arm weakness, not for missing limbs.The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices 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 the MyoPro myoelectric orthosis (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implant body, endosteal implant,
tooth 3, 14 (D6010) cone beam CT scan (D0367).
You asked the Plan to pre-approve the dental services. You say that if you had been informed that this provider
was no longer participating in your network you wouldn't have rescheduled with this office. The Plan denied
your request. The Plan says these services are not covered under the plan 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. Services not listed under list of
covered dental procedures are not covered.
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 pre-approve
surgical placement of implant body, endosteal implant, tooth 3, 14 (D6010) cone beam CT scan (D0367).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first
intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), and panoramic x-ray (D0330)
provided on February 27, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation, intraoral periapical x-rays, and
panoramic x-ray. You say that it was medically necessary for you to receive these dental procedures so you
could get a release for surgery. The Plan denied your request. The Plan says these services are not covered by
the Plan. The Plan also says that you did not elect to purchase optional supplemental dental coverage.
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
problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), additional intraoral
periapical x-ray (D0230), and panoramic x-ray (D0330) provided on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care (99291) provided on November 4, 2019.
You asked the Plan to pay for critical care. You say that this should be covered. The Plan denied your request. The Plan says this service has already been billed.
The Plan must follow Medicare rules. Medicare rules say that that physicians in the same group practice who have the same specialty may not each report CPT initial critical care code 99291 for critical care services to the same patient on the same calendar date. We looked at the file and Medicare rules. The record shows that CPT 99291 was previously billed by a physician with the same specialty for the date of service at issue. Based on this information, we decided that Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care (99291) provided on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the out of area office visit provided on May 22, 2019.
You asked the Plan to pay for the out of area office visit. You say that you would like the Plan to reconsider
their denial of payment. The Plan denied your request. The Plan says the services received were neither
emergent nor urgent and prior authorization was not obtained to seek out of area care.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care.
We looked at the file and Medicare rules. The file shows the services you received were office visit services
that were neither emergent nor urgent and prior authorization was not obtained to seek out of area office visit
services. Based on this information, we decided that Medicare rules for coverage of the out of area office visit
have not been met. Therefore, we decided that the Plan does not have to pay for the out of area office visit
provided on May 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on February 7, 2020.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that this provider took several x-rays. You also say that you are sure this provider knew which types of x-rays were not covered. 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. Your plan only covers bitewing x-rays. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe Part B drugs and x-ray services provided in anoutpatient hospital from March 8, 2020 to March 9, 2020.You asked the Plan to waive the cost share forthe Part B drugs and x-ray services. You say that you would like the Plan to reconsider your request.The Plan denied your request. The Plansays you received Part B drugs and x-ray services during you outpatient stay on the dates of service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan. The Plan says you are only responsible forpaying your cost share, if you have not already done so, of $55.87.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 Planclearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs and a $100 copayment for outpatient basic radiological services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you were admittedas outpatient from March 8, 2020 to March 9, 2020. You received Part B drugs during your outpatient stay. You have been asked to pay a 20% coinsurance for the Part B drugs, totaling $44.87. The Part B drugs fall within the Medicare Part B prescription drugs benefit category. You also received x-ray services during your outpatient stay. You have been asked to pay a $10 copayment for the x-ray services, which is less than the contracted $100 copayment amount. The x-ray services fall within the Outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amounts based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Please note, you are only responsible for your cost share amount, totaling $55.87.Therefore, we decided that the Plan does not have to waive the cost share forthe Part B drugs and x-ray services provided in an outpatient hospital from March 8, 2020 to March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the spa purchased on August 20, 2019.
You asked the Plan to reimburse you for the spa. You say that your doctor prescribed a jacuzzi for your condition. The Plan denied your request. The Plan says you obtained durable medical equipment from a provider who does not participate 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. Payment cannot be made for items purchased from this provider because this provider is not a medical provider and is not enrolled in Medicare. Therefore, we decided that the Plan does not have to reimburse you for the spa purchased on August 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Slumber Solution 10 inch Gel Memory foam mattress, plus firmness, size queen or twin.
You asked the Plan to pre-approve the Slumber Solution 10 inch Gel Memory foam mattress. You say that you have neuropathy and is unable to sleep comfortably. Due to your uncomfortable bed you have developed severe pain in your hips. You do not have the funds to purchase a new mattress on your own. The Plan denied your request. The Plan says the requested item is a standard mattress size. This is a commercial furniture item and is not the same as a hospital bed mattress.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the Slumber Solution 10 inch Gel Memory foam mattress, plus firmness, size queen or twin.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 1, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed,
however, the physician must clearly document, in the medical record, his or her intent that the test be
performed.
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided
that the Plan does not have to pay for the laboratory services provided on August 1, 2019.