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

We decided that the Plan does not have to pre-approve Repatha Sure Inj.
You asked the Plan to pre-approve Repatha Sure Inj. 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 Repatha Sure Inj.
Benefits for Repatha Sure Inj 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus, poliovirus, and haemophilus influenza type B vaccines provided on September 29, 2020.
You asked the Plan to pay for the vaccines. 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.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccines. The Plan follows the same rules. Records do not show that the enrollee had been injured or directly exposed to any illness related to the vaccines. Therefore, we decided that the Plan does not have to pay for the tetanus, poliovirus, and haemophilus influenza type B vaccines provided on September 29, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the physician services provided on December 15, 2020.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment as you were referred by an in-network provider. The Plan denied your request. The Plan says that the services are not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the physician services by a contract provider. The file does not show that the Plan provided notice that the physician services would not be covered. Under Medicare rules, this means the physician services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the physician services provided on December 15, 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 pay for the dental services (D0150, D0368, D9999) provided on December 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the dental services. You say that you saw an in-network dentist first, but they were unable to solve your problem. The Plan denied your request. The Plan says out-of-network dental care 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. The Plan will only cover dental services when they are provided in-network. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested provider in this case is not a network provider with the Plan. The Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the dental services (D0150, D0368, D9999) provided on December 9, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone replacement graft (D7953), and an extraction (D7140) provided on November 24, 2020.
You asked the Plan to pay for a bone replacement graft, and extractions. You say that you would like the Plan to pay for these services. The Plan denied your request. The Plan says the extraction is a covered benefit, but the frequency limit of one every year has been met. The bone replacement graft is 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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a bone replacement graft, and an extraction have not been met. Specifically, the record shows that the frequency limit for extractions has been reached. Additionally, a bone replacement graft is not a covered service. Therefore, we decided that the Plan does not have to pay for a bone replacement graft (D7953), and an extraction (D7140) provided on November 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fitness center membership used January 1, 2021, through January 31, 2021.
You asked the Plan to pay for the January 2021 fitness center membership. You say that you should have had coverage starting January 1, 2021, and the direct payment requirement is new. The Plan denied your request. The Plan says you did not directly enroll in the fitness benefit until February 3, 2021; therefore, the January fitness center fees are not covered by the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. The services at issue in this appeal are gym benefits. You were not enrolled in gym benefits until February 3, 2021. Therefore, we decided that the Plan does not have to pay for the fitness center membership used January 1, 2021, through January 31, 2021.
Your complaint about new enrollment requirements for the Plan's fitness program is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine vision services described by codes 92015 and 92310 provided on December 7, 2020.

You asked the Plan to pay for codes 92015 and 92310. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received routine vision services with a non-participating provider within your vision network.

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 these services when they are provided by a participating provider in your vision network.

We looked at the file and the Plan's rules. The file shows that you received the routine vision services provided by a provider that is not in your vision benefit network. Based on this information, we decided that the Plan's rules for coverage of codes 92015 and 92310 have not been met. Therefore, we decided that the Plan does not have to pay for the routine vision services described by codes 92015 and 92310 provided on December 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on January 16, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 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 laboratory work provided on January 16, 2021 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 7, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, the submitted claim was billed with a laboratory place of service code while the record indicates the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure (CPAP) equipment provided January 19, 2021.

You asked the Plan to waive the coinsurance for the CPAP equipment. You say that you believe you should be charged nothing for this equipment. The Plan denied your request. The Plan says the coinsurance processed correctly in this case.

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 durable medical equipment and related supplies. 

You have been asked to pay a total cost share of $87.01 ($435.06 Medicare allowed amount x 20% coinsurance). These items fall within the durable medical equipment and related supplies 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 the continuous positive airway pressure (CPAP) equipment provided January 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator (E1390NU) provided September 27,
2020.

You asked the Plan to pay for the oxygen concentrator. You say that this service was medically necessary. The
Plan denied your request. The Plan says this is not a covered service under your policy.

The Plan must follow Medicare rules. Medicare rules say that payment can only be made once during a 6-
month period for oxygen equipment after the requirements listed in the Medicare rules section have been
satisfied.

We looked at the file and Medicare rules. The file indicates that this service was previously provided during the
sixth month window. Based on this information, we decided that Medicare rules for coverage of the oxygen
concentrator have not been met. Therefore, we decided that the Plan does not have to pay for the oxygen
concentrator (E1390NU) provided September 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) provided on November 16, 2020.
You asked the Plan to pay for the crown. You say that you would like this service to be covered under your medical insurance. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not elect to purchase an optional supplemental 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 pay for the crown (D2740) provided on November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99219, 99215) provided from September 2,
2020, to September 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says only one unit of these
codes is supported.
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 additional units of CPT code 99219 and 99225 are not supported in the medical record.
Specifically, the records provided support the one unit of CPT code 99219 and one unit of CPT code 99225
were provided for the dates of service in question. The Plan has paid for one unit of each code. 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 pay for the services (99219, 99215) provided from September 2, 2020, to
September 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization
device (22869).

You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan
denied your request. The Plan says this service is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer
found that the Superion spacer is experimental. More research is needed to show safety and efficacy of the
device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not
have to pre-approve the insertion of a Superion interspinous stabilization device (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided
on December 9, 2020.

You asked the Plan to pay for the topical application of fluoride varnish. You say that you believe this service
should be 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. Therefore, we decided that the Plan does not have to pay for the
topical application of fluoride varnish (D1206) provided on December 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 3, 2020.

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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99308) and debridement (11043)
provided on December 4, 2020.
You asked the Plan to pay for the nursing facility care and debridement. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says these codes are
duplicates to the services processed and paid under another claim.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined
to be an exact duplicate are rejected and do not have appeal rights.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the nursing facility care and debridement have not been met. Specifically, the record indicates that
these codes are duplicates to services that have previously been processed and paid by the Plan. Therefore, we
decided that the Plan does not have to pay for the nursing facility care (99308) and debridement (11043)
provided on December 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Flexitouch advanced PCD provided by an out of network (OON) provider.
You asked the Plan to pay for the Flexitouch advanced PCD. You say that the service is medically necessary The Plan denied your request. The Plan says the provider is out-of-network.
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 had network providers available who could have provided the items/services at issue in this appeal. The record shows if the member were to have an extended trial of the in-network PCD and it were to fail, future consideration of an out of network exception would be made.
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 Flexitouch advanced PCD provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from September
14, 2020, to September 15, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you should not be responsible
for the copayment because it states in the EOC that if admitted after a trip to the emergency room, you do not
have to pay for the admission. The Plan denied your request. The Plan says you have been asked to pay 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 $200
copayment for medically necessary in-network inpatient hospital care. For this date of service, you have been
asked to pay the allowed amount of the claim because this amount is less than the standard $200 copayment for
the inpatient stay.
You have been asked to pay a $183.56 copayment for the inpatient stay. The inpatient stay falls within the
"Inpatient hospital care" benefit category. The record shows you were admitted as an inpatient and the inpatient
copayment was applied. The record shows the emergency room copayment was waived.
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 inpatient stay provided from September 14, 2020, to
September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the coinsurance for the dialysis services (90999) provided from October 28, 2020, through November 30, 2020.
You asked the Plan to adjust the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the services provided.
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 dialysis treatment. You have been asked to pay $951.58 (Plan allowed amount of $339.85 x 20% =$67.97 x 14 treatments) for the kidney dialysis services provided. 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 adjust the coinsurance for the dialysis services (90999) provided from October 28, 2020, through November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal adjustment (D9951) for teeth # 8, 25, and 31 provided on November 10, 2020.
You asked the Plan to pay for the dental services. You say that you tripped and fell, chipping several teeth and biting through your lower lip. You say that you were not able to see the dentist until September 2020 due to pre-surgery colon issues, Covid-19 quarantine, and your recovery. The Plan denied your request. The Plan says the services you received are dental in nature. The Plan says that routine dental services are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the occlusal adjustment (D9951) for teeth # 8, 25, and 31 provided on November 10, 2020.