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

We decided that the Plan does not have to pre-approve six resin-based composites (D2332 x4, D2391, and D2391), a crown (D2740), core buildup, including any pins when required (D2950), and post and core in addition to crown (D2952). 
 
You asked the Plan to pre-approve the resin-based composites, crown, core buildup, and post and core. You say that the Plan representatives told you that the repairs to your teeth would be covered under your medical coverage. You also say that you cannot easily pay out of pocket for these services. The Plan denied your request. The Plan says the annual maximum benefit has been reached. 
 
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 Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The Plan decided to pre-approve $888 of the cost of the crown (D2740). The remainder of the services will remain denied because you exhausted the maximum dental benefit. Therefore, we decided that the Plan does not have to pre-approve six resin-based composites (D2332 x4, D2391, and D2391), a crown (D2740), core buildup, including any pins when required (D2950), and post and core in addition to crown (D2952).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the parental nutrition supplies provided from July 19, 2019 to July 26, 2019.
You asked the Plan to pay for the parental nutrition supplies. The Plan denied your request. The Plan says that there is no proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the parental nutrition supplies provided from July 19, 2019 to July 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp.
You asked the Plan to pre-approve a wheelchair ramp. You say that you need a wheelchair ramp to get in and out of your house. The Plan denied your request. The Plan says wheelchair ramps are not primarily medical equipment and are 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. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Medicare does not cover home modifications. Also, the item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown, three core buildups, including any pins when
required, three retainer crowns, and a maxillary partial denture.
You asked the Plan to pre-approve the crown, core buildups, retainer crowns, and maxillary partial denture.
The Plan denied your request. The Plan says these services are not covered under your 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, 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 a
crown, three core buildups, including any pins when required, three retainer crowns, and a maxillary partial
denture.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the emergency room (ER) visits and skilled
nursing facility (SNF) services provided to the enrollee from August 14, 2019 to September 17, 2019.
You asked the Plan to waive the copays for the ER visits and SNF services. The Plan denied your request. The
Plan says that the enrollee was charged correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $50 copay for Medicare-covered emergency care and a $75 copay for days 21-65 of SNF care.
The enrollee has been asked to pay a $50 copay for each of the three ER visits and a $75 copay for each of the
eight days of SNF services. The ER visits fall within the Medicare-covered emergency care and the SNF
services fall with days 21-65 of SNF care benefit category. This means that the enrollee has been asked to pay
the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copays
for the emergency room (ER) visits and skilled nursing facility (SNF) services provided to the enrollee from
August 14, 2019 to September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physician services provided on
January 6, 2020 and January 21, 2020.
You asked the Plan to waive the copayments for the physician services. You say that you feel you should not
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan
denied your request. The Plan says you received physician services on the dates of service at issue in this
appeal. The Plan states the correct copayments have applied per your contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10
copayment for Physician/Practitioner services.
We looked at the file, the Plan's contract and Medicare rules. The file shows you received physician services on
January 6, 2020 and January 21, 2020. You have been asked to pay a $10 copayment for each date of service.
The physician services fall within the Physician/Practitioner 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 copayments for the physician services provided on January 6, 2020 and January 21,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for genetic testing provided by a participating provider on January 9, 2020.
You asked the Plan to waive the coinsurance for genetic testing. You say that you did not have genetic testing done. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for outpatient diagnostic tests/genetic testing. You have been asked to pay a 20% coinsurance of the allowed amount for genetic testing. The total allowed amount is $120.90. The total amount you are being asked to pay is $24.18 ($120.90 x 20% = $24.18). The correct coinsurance has been applied to the services that were provided. Genetic testing falls within the outpatient diagnostic tests/genetic testing benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for genetic testing provided by a participating provider on January 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation therapy for prostate adenocarcinoma.You asked the Plan to pre-approve radiation therapy for prostate adenocarcinoma. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 radiation therapy for prostate adenocarcinoma. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than intensity-modulated radiation therapy/image-guided radiation therapy (IMRT/IGRT). The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to enrollees.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiation therapy for prostate adenocarcinoma have not been met.Therefore, we decided that the Plan does not have to pre-approve radiation therapy for prostate adenocarcinoma.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 29, 2019 to September 16, 2019 by a non-contracted provider.
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 were rendered by a non-contracted provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The 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 medical services provided on April 29, 2019 to September 16, 2019 by a non-contracted provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99285) provided on December 4, 2019.You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says G92 is not appropriate as a primary diagnosis code.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 99285 is not supported in the record. Specifically, this claim has been billed with G92 as the primary diagnosis code. Per CMS's ICD 10 Coding Guidelines, G92 is a "code first" code. This means the another code should be listed first to identify the reason for G92 or toxic encephalopathy. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met.Therefore, we decided that the Plan does not have to pay for an emergency department visit (99285) provided on December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided July 29, 2019.
You asked the Plan to pay for the vision services. You say that you are requesting reconsideration of the decision to deny payment of $313 for services. Your primary care provider had approved the referral to see this provider. The Plan denied your request. The Plan says the primary explanation of benefits from the primary carrier is needed in order to complete the review of the claim.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. As the secondary insurer, the Plan cannot be held responsible for the vision services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the vision services provided July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient visit (G0463). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says non-urgent services should be from network providers who are contracted with the healthplan and listed in the Provider Directory.
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 medical services provided on August 14, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 19, 2018 through August 20, 2018.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 19, 2018 through August 20, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stiolto Aer 2.5/2.5.You asked the Plan to pre-approve Stiolto Aer 2.5/2.5. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.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 Stiolto Aer 2.5/2.5.Benefits for Stiolto Aer 2.5/2.5may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral/facial images (D0350) tooth molds (D0470) other drugs and/or medicines (D9630) and alveoloplasty in conjunction with extractions (D7310).
You asked the Plan to pre-approve the dental services. You say that you have been trying since January 1, 2020 to get this appointment and approval for teeth implants and you request reconsideration so that this necessary health work may be completed. The Plan denied your request. The Plan says these services are not covered under the plan benefits. The alveoloplasty does not meet plan coverage the criteria.
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 alveoloplasty is only covered when there is a minimum of 4 extractions present per quadrant. In this case there is only 1 tooth /area that would need the procedure. Therefore, the plan coverage criteria is not met. 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 oral/facial images (D0350) tooth molds (D0470) other drugs and/or medicines (D9630) and alveoloplasty in conjunction with extractions (D7310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.You asked the Plan to pre-approve a stair lift. The Plan denied your request. The Plan says that this item is not covered by Medicare.The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a stair lift
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bath rail.
You asked the Plan to pre-approve a bath rail. You say that you need this to stabilize yourself getting in and out of the shower. The Plan denied your request. The Plan says that a bath rail does not serve a purpose that is primarily medical in nature and is considered a convenience item because it is not used to treat a medical condition.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a bath rail
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zyprexa 7.5mg tablet.
You asked the Plan to pre-approve Zyprexa 7.5mg tablet. You say that the requested medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Zyprexa 7.5mg tablet.
Benefits for Zyprexa 7.5mg tablet 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Duplex Scan (93970) provided December 16, 2019.
You asked the Plan to waive the copayment for the Duplex Scan. You say that the copayment shouldn't be charged because the MRI was never completed. The Plan denied your request. The Plan says the copayment is not for the MRI, but for a Duplex scan that was completed.
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 Outpatient Diagnostic Testing. You have been asked to pay an $80 copayment for the Duplex Scan. The Duplex Scan falls within the Outpatient Diagnostic Testing 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 a Duplex Scan (93970) provided December 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
January 7, 2020.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration
because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating
room during the length of the procedure. The Plan denied your request. The Plan says payment for this service
is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for
coverage of the pump assembly and operation have not been met. Specifically, payment for this service is
included in the DRG payment to the facility and it is the responsibility of the facility to any vendor. Therefore,
we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
January 7, 2020.