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

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and surgical extraction (D7210) to be provided by an oral surgeon.
You asked the Plan to pre-approve the dental services. You say that you had a cap coming off your tooth. You say that you were referred to an oral surgeon for an extraction because the dentist was unable to perform the procedure. You also say that you are concerned you may get an infection. The Plan denied your request. The Plan says dental services must be provided by a participating general dentist in order to be covered. The Plan also says services provided by an oral surgeon are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and surgical extraction (D7210) to be provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power operated vehicle.
You asked the Plan to pre-approve a Group 1 power operated vehicle. You say that you need a scooter to get to the dining hall. The Plan denied your request. The Plan says your provider record indicates you have full strength in your arms and use a walker.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows your condition can be improved by a walker, cane or manual wheelchair. 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 Group 1 power operated vehicle.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve office visits. You say that there are only two doctors who can provide these services. You say that the other doctor is too far. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to you for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. You are not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to you for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G myoelectric limb orthosis.
You asked the Plan to pre-approve a powered upper extremity range of motion assist device (L8702). You say that the enrollee needs a powered upper extremity range of motion assist device to be independent in all ADLs and return to gainful employment. The Plan denied your request. The Plan says a review of the current medical literature indicates that this device is considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary, and are experimental and investigational are not covered. We looked at the file and Medicare rules. There is insufficient medical record information submitted to show this orthosis would be preferred or more effective than the traditional upper orthosis types that are covered by Medicare. Based on this information, we decided that Medicare rules for coverage of a powered upper extremity range of motion assist device (L8702) have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro Motion G myoelectric limb orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiogram provided on October 21, 2019.
You asked the Plan to waive the copayment for the echocardiogram. You say that you should not be responsible for the $100 copayment because the procedure took less than 15 minutes and you do not believe it should cost this much. 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 a $100 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). You have been asked to pay a $100 copayment for the echocardiogram. The echocardiogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows that an echocardiogram is considered an ultrasound of the heart.
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 the echocardiogram provided on October 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided by an outpatient hospital facility on December 4, 2019.
You asked the Plan to waive the copayment for an MRI. You say that this was not an outpatient hospital. The Plan denied your request. The Plan says the correct copayment has been 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 $100 copayment for outpatient diagnostic tests/advanced imaging services. You have been asked to pay a $100 copayment for an MRI. The rendering facility is considered an outpatient hospital; therefore, the correct copayment has been applied. An MRI falls within the outpatient diagnostic tests/advanced imaging services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an MRI provided by an outpatient hospital facility on December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant placement, gum surgery, a bone graft, and fillings for teeth # 3 and 5.
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says implant placement, gum surgery, and bone graft are not listed as covered service. The Plan also says the frequency limit for the fillings has been exceeded.
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 implant placement, gum surgery, and bone graft are not among those covered under this benefit. Additionally, the frequency limit for fillings has been exceeded. The record shows that the Plan paid for fillings on teeth # 3 and 5 that you received on January 31, 2019. Therefore, we decided that the Plan does not have to pre-approve an implant placement, gum surgery, a bone graft, and fillings for teeth # 3 and 5.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a septoplasty procedure.
You asked the Plan to pre-approve these services. You say that you can't breathe properly through your nose. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a septoplasty is covered when specific criteria 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have a septal deviation that causes nasal airway obstruction. The records do not show that you have tried and failed a recent trial of conservative medical management for at least six weeks. Therefore the requested septoplasty does not meet the criteria for coverage and is 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 pre-approve a septoplasty procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.
You asked the Plan to pre-approve a CGM and supplies. You say that The Plan denied your request. The Plan says that the enrollee is only testing her blood sugar 2-3 times daily.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met. We looked at the file and Medicare rules. The file indicates the enrollee is not testing her blood glucose four or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveextraction of tooth #31 (D7140) provided January 8, 2020.You asked the Plan to pre-approvethe dental services. You say that you have been going to this dental school for 30 years and would like to continue to go.The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being renderedMedicare 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 contract says services obtained from vendors outside the network 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-approveextraction of tooth #31 (D7140) provided January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursementforthe alveoloplasties(D7310x2), the deep sedation/general anesthesia-first 15 minutes (D9222), the deep sedation/general anesthesia-each subsequent 15 minute increment (D9223), therapeutic parenteral drugs, two or more administrations, different medications (D9612), and surgical placement of an implant (D6010) provided on September 26, 2018.You asked the Plan to issue reimbursement 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 that the services provided are not a covered benefit under your contractual dental policy.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 services provided are not among those covered under this benefit.Therefore, we decided that the Plan does not have to issue reimbursementforthe alveoloplasties(D7310x 2), the deep sedation/general anesthesia-first 15 minutes(D9222), the deep sedation/general anesthesia-each subsequent 15 minute increment (D9223), therapeutic parenteral drugs, two or more administrations, different medications (D9612), and the surgical placement of an implant (D6010) provided on September 26, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that the enrollee has uncontrolled blood sugars and can test more easily with the CGM. The Plan denied your request. The Plan says the enrollee does not require insulin. Medicare does not cover CGMs for those who are not insulin-dependent.
The Plan must follow Medicare rules. Medicare rules say that CGMs are covered for enrollees who must test frequently, and perform frequent insulin injections which require adjustment based on the readings from the monitor. In this case, the enrollee does not require insulin. As such, the Medicare coverage criteria for the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes 95939, 95938, 95861, and 95868 provided on November 4, 2018.
You asked the Plan to pay for CPT codes 95939, 95938, 95861, and 95868. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee received these services in the facility during an inpatient hospitalization and payment for these services would be included in the Part A-DRG payment to the facility. The Plan states payment for these services is the responsibility of the facility.
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we decided that the Plan does not have to pay for CPT codes 95939, 95938, 95861, and 95868 provided on November 4, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on December 9, 2019 to December 11, 2019.You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you never got yourown private room. You say that you had to share a bathroom with other patients. You say that you do not think that you should be charged for this. The Plan denied your request. The Plan says the correct copayment has been 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 $250 copayment per day for days 1-7. There is a $0 copayment for additional days for inpatient hospital coverage. You have been asked to pay a $250 copayment per day for days 1-7 for an inpatient hospital stay. The total amount you are being asked to pay is $250 (admitted as an inpatient on December 10, 2019). An inpatient hospital stay falls within the inpatient hospital coverage 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 by on December 9, 2019 to December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99213) and osteopathic manipulative treatment (98929) provided on October 29, 2019.You asked the Plan to pay forthe office visit and osteopathic manipulative services. You say that you would like reconsideration because there are no other providers that offer this service.The Plan denied your request. The Plan says the provider has opted out of Medicare and there is no authorization on file.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 a provider who has opted out of Medicare.Therefore, we decided that the Plan does not have to pay forthe office visit (99213) and osteopathic manipulative treatment (98929) provided on October 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on November 4, 2019.
You asked the Plan to pay for the pathology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 and the ordering physician are not network providers with the Plan. The Plan did not pre-approve the pathology services. 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 pathology services provided on November 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endosteal implant (D6010) provided on November 11, 2019.
You asked the Plan to pay for the dental service. You say that you called the plan to find an in network periodontist. You say that the plan representative approved the entire 2-part procedure, the extraction and implant. The Plan denied your request. The Plan says endosteal implants are not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the endosteal implant is not listed as a covered service. The Plan's call log confirms the only issue addressed over the phone was finding an in network periodontist. Therefore, we decided that the Plan does not have to pay for the endosteal implant (D6010) provided on November 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore build-up, including any pins tooth 29 (D2950) and crown tooth 2 (D2750).You asked the Plan to pre-approvethe dental service. You say that you are appealing the denial of these services are listed as covered in the member handbook.The Plan denied your request. The Plan says the requested 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.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-approvecore build-up, including any pins tooth 29 (D2950) and crown tooth 2 (D2750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751) for tooth # 31.
You asked the Plan to pre-approve the dental service. You say that your previous crown broke. You also say that you need a new one. The Plan denied your request. The Plan says crowns are not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown (D2751) for tooth # 31.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on October28, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not a covered benefit.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 forthe laboratory services provided on October 28, 2019 by an out of network (OON) provider.