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

We decided that the Plan does not have to waive the copayment for an emergency room visit provided March 18, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment 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 an $80 copayment for Emergency Care. You have been asked to pay an $80 copayment for the emergency room visit. The emergency room 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 emergency room visit provided March 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2393) provided on February 20, 2020. 
 
You asked the Plan to pay for the resin-based composite. You say that you were not informed of what you would be charged prior to receiving the service. You also say that the office never explained to you what the Plan covered and what was not covered. The Plan denied your request. The Plan says this service is not covered by the 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resinbased composite (D2393) provided on February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses rendered on January 13, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are only covered from an in-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $300 towards routine eyewear from a network optical provider once per calendar year. We looked at the file and the Plan's rules. The file shows that you did not receive services from a network optical provider. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses rendered on January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on February 25, 2020.You asked the Plan to pay for the prophylaxis. You say that your appeal is based on inconsistencies with policy provision that covers reimbursement for services by a licensed dentist. You also say that the Annual Notice of Changes for 2020 makes no reference to any changes from the 2019 plan in denial reimbursement coverage.The Plan denied your request. The Plan says this provider opted out of Medicare, effective May 31, 2016 to May 31, 2022. The Plan also says that the Health Plan cannot issue payment for services performed by an opt out provider.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment. The records show that no calls were received from you prior to the date of service regarding your dental benefits.Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard wheelchair. You asked the Plan to pre-approve a standard wheelchair (K0001). You say that you need a wheelchair because you cannot walk due to a medical condition.The Plan denied your request. The Plan says there is no documentation of your mobility limitation or that your home provides adequate access and maneuvering space for the requested documentation.The Plan follows Medicare rules. Medicare rules say that a manual wheelchair will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, or the patient's condition can be ameliorated by a walker or cane, or the enrollee's home does not provide adequate access for use of the manual wheelchair.The file does not show that your condition cannot be improved by a walker or cane. There is no home assessment in the file.This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approve a standard wheelchair.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99283 and the control nasal hemorrhage services coded 30903 provided on March 12, 2019. You asked the Plan to pay for the emergency department visit and the control nasal hemorrhage services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 99283 and 30903 are not supported in the medical record. Specifically, code 30903 was billed without a required anatomical modifier. Based on this information,we decided that Medicare rules for coverage of the emergency department visit and the control nasal hemorrhage services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99283 and the control nasal hemorrhage services coded 30903 provided on March 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for250 units of an unspecified compounded drug (J7999).You asked the Plan to pay forthe drug. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the number of units billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We asked our coder 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 forthe drug. Our reviewer says that the 250 units of J7999 do not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation does not support the 250 units of unspecified compounded drugs billed.We looked at this coder'sreview, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met.Therefore, we decided that the Plan does not have to pay for250 units of an unspecified compounded drug (J7999).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 8, 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 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an immediate mandibular denture.
You asked the Plan to pre-approve the immediate mandibular denture. You say that your lower denture is too
loose, and you have to take it out in order to sleep. You also say that the denture comes out when you eat, and it
is very uncomfortable and hurts your gums. The Plan denied your request. The Plan says you have exhausted
your denture benefit of once per 5 years.
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, dentures are limited to 1 per 5 years.
The record shows that you received an upper and lower denture on December 11, 2019 and your dentures
benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve an immediate
mandibular denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 8, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained.
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 physician services provided on January 8, 2020 by
an out of network (OON) provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after July 24, 2020.
You asked the Plan to pre-approve SNF care. You say that the continuation of SNF care is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for the continuation of SNF care.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before July 24, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after July 24, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you love walking but your feet burn and you need new orthotics.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.
You asked the Plan to pre-approve Hyalgan. You say that the requested Hyalgan is medically necessary. The
Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Monovisc first.
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 Hyalgan. Our reviewer says that the
Plan's step therapy criteria have not been met. Our physician reviewer found the review indicates that the
enrollee is with osteoarthritis of the knee. The Plan's preferred viscosupplements are Orthovisc and Monovisc
and don't require prior authorization. The benefit provides coverage for the requested viscosupplement when
medically necessary. However, the information submitted doesn't meet the Plan's medical necessity guidelines
for coverage. The member must meet the following criteria: has had previous treatment, contraindication, or
intolerance to Orthovisc and Monovisc.
The review has determined that the Plan requires a trial of drugs Orthovisc and Monovisc first before they will
approve the requested drug. The review indicates that the enrollee has not tried and failed the required drug(s).
There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective
and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have
to pre-approve Hyalgan.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four home physical therapy and occupational therapy home health services. You asked the Plan to pre-approve the services. You say that this is medically necessary, as without these services you would be stuck in bed 24 hours a day, and it is not a good quality of life. The Plan denied your request. The Plan says Medicare coverage criteria has not been met. The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found you are noted to be chronically weak, homebound and bedbound. There is no evidence of a recent change in your condition. There is no evidence that you are in need of in-home skilled therapy services. The requested services are not shown to be 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve four home physical therapy and occupational therapy home health services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray (73110) provided January 9, 2020.
You asked the Plan to waive the copayment for the x-ray. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost sharing 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 a $35 copayment for x-rays provided in a specialist's office. You have been asked to pay the allowed amount of $34.12 for the x-ray. The x-ray falls within the x-rays provided in a specialist's office benefit category. In this case, the allowed amount was less than the $35 copayment listed in the plan contract. 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 x-ray (73110) provided January 9, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for hyperbaric oxygen therapy provided to the enrollee on March 23, 2020.
You asked the Plan to pay for the therapy. You say that records have been sent to support the medical necessity
of this service. The Plan denied your request. The Plan says that this does not meet the NCD criteria.
The Plan must follow Medicare rules. Medicare rules say that hyperbaric oxygen therapy is covered under
certain limited condition.
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 therapy. Our reviewer says that the
therapy at issue in this case is medically reasonable and necessary. Our physician reviewer found the enrollee
has a Grade III ulcer and has been recommended to complete 40 Hyperbaric Oxygen Therapy treatments. The
enrollee has a diabetic wound that meets the criteria. The review indicates that the enrollee has a covered
indication for HBO therapy.
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 therapy have been met. Therefore, we decided that the Plan has to pay for
hyperbaric oxygen therapy provided to the enrollee on March 23, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removable unilateral upper partial denture (D5282).
You asked the Plan to pre-approve the dental services. You say that you were initially approved for a bridge.
Now you are trying to get the work done and you would like the previous approval extended since you were
not able to get it done in time due to COVID. The Plan denied your request. The Plan says this service is 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.
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
removable unilateral upper partial denture (D5282).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive procedure provided on January 15, 2020.You asked the Plan to pay for the adjunctive procedure. You say that you have filed claims for this dentist with your previous plan and the claims were paid. You also say that trying to find a dentist in your area that accepts Medicare is impossible.The Plan denied your request. The Plan says you received dental services from an opt out provider. The Plan also says that the Plan cannot issue payment for services performed by an opt out provider.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay for the adjunctive procedure provided on January 15, 2020.