Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested varicose vein treatment.
You asked the Plan to pre-approve the varicose vein treatment. The Plan denied your request. The Plan says that the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested varicose vein treatment.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injections in your left knee.
You asked the Plan to pre-approve injections. You say that you need this injection to give you
better mobility with less pain. The Plan denied your request. The Plan says this drug has not been proven to be
safe or helpful for patients with this diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
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 injections. Our reviewer
says that the enrollee had a history of left knee pain. Left knee exam documented no effusion, full range of
motion, pain at extremes of extension and flexion, positive medial  test, good tracking and no
ligament instability. X-rays were reviewed and showed no bony abnormalities. The diagnosis included
probable left knee medial meniscus tear with more than 5 months of symptoms. Authorization was requested
on March 27, 2020 for one injection to the left knee for a diagnosis of left knee patella
chondromalacia.
Our physician reviewer found Medicare coverage criteria have not been met. There is no radiographic evidence
of osteoarthritis of the knee, including joint space narrowing, subchondral sclerosis, osteophytes, or
subchondral cysts. The documentation submitted does not support that the Synvisc-One injection would be
considered medically reasonable and necessary or safe and effective for the enrollee's medical condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of  injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve  injections in your left knee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 6.You asked the Plan to pre-approve the core build up. You say that tooth # 6 has recurrent decay on the distal surface of the tooth on the existing full coverage crown. You also say that in order to properly restore the tooth, a new full coverage crown is necessary.The Plan denied your request. The Plan says core build up is not listed as 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 core build up is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 6.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 7, 2019.
You asked the Plan to waive the copayment for the office visit. You say that the office did not secure authorization or a referral. You say that you aren't responsible for the bill. The Plan denied your request. The Plan says the copayment applied 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). Your contract with the Plan clearly says that you must pay a $50 copayment for provider and professional services at an in-network specialist's office. You have been asked to pay a $50 copayment for the office visit.

The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 the office visit provided on November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD) provided on January 16, 2019. You asked the Plan to waive the copayment for EGD. You say that a diagnostic test billed by the in-network hospital should only have a $20 copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct. 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 $400 copayment for in-network EGD at an outpatient hospital. This EGD is considered to be a surgical service, therefore the outpatient surgery copayment applies to this claim. You have been asked to pay $400 copayment for EGD. EGD falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 esophagogastroduodenoscopy (EGD) provided on January 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a pneumatic compression device.
You asked the Plan to provide a pneumatic compression device (E0652). You say that the enrollee has had no significant improvement undergoing conservative treatments. The Plan denied your request. The Plan says there is no record of a four week trial.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to provide a pneumatic compression device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 15,
2020.
You asked the Plan to waive the copayment for the office visit. You say that you were informed the provider is
in-network. The Plan denied your request. The Plan says the copayment applied 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). Your contract with the Plan clearly says that you must pay a $25
copayment per Medicare-covered service from an out-of-network provider.
You have been asked to pay a $25 copayment for the office visit. The office visit falls within the "Chiropractic
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 the office visit provided on
January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus vaccine you received on December 11, 2019.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this vaccine is not covered under Part C.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus vaccine you received on December 11, 2019.
Benefits for the vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on December 3, 2019.You asked the Plan to pay for the dental service. You say that x-rays are typically covered. You say that you did not know that panoramic x-rays were different from bite wing x-rays and would not be covered. You also say that you called the Plan and were advised that x-rays were covered.The Plan denied your request. The Plan says panoramic x-rays are not listed as 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 panoramic x-ray is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe panoramic x-ray (D0330) provided on December 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction services (92015) provided on December 5, 2019.
You asked the Plan to pay for the refraction services. You say that the test should have been billed as a routine service and you are requesting reimbursement for the cost of the refractive exam. The Plan denied your request. The Plan says refractive services are not covered under the plan benefit unless rendered by an EyeQuest 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 this service when provided by an EyeQuest vision care provider. The plan has confirmed that the provider is not an EyeQuest vision care provider.
We looked at the file and the Plan's rules. This service is only covered when provided by an EyeQuest vision care provider. Based on this information, we decided that the Plan's rules for coverage of the refraction services have not been met. Therefore, we decided that the Plan does not have to pay for the refraction services (92015) provided on December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine one-way transportation trips
You asked the Plan to pre-approve the additional trips. You say that you have dialysis 3 times a week and you
should receive as many trips that you need. This is life sustaining treatment and you can die if you do not go to
dialysis and this is delaying your treatment. The Plan denied your request. The Plan says this request exceeds
the benefit limits
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 50 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional routine one-way transportation trips
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on January 13, 2020.You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that these services have been covered in the past.The Plan denied your request. The Plan says you were enrolled in a dental plan from January 1, 2018 to December 31, 2018. The Plan also says that you did not have an active dental plan during the time these services were provided.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 periodic oral evaluation and prophylaxis provided on January13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Latanoprost Solution for enrollee.You asked the Plan to pre-approve Latanoprost. You say that the enrollee has been successfully treated with this medication.The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.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 Latanoprost Solution for enrollee.Benefits for Latanoprost 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the inversion table.
You asked the Plan to pre-approve the inversion table. You say that you have been to chiropractors for lower
back pain for years and nothing has relieved your lower back pain better than an inversion table. The Plan
denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules say that experimental and investigational devices are not covered.
Therefore, we decided that the Plan does not have to pre-approve the inversion table (E1399).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from December 3, 2019 to December 31, 2019.
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 claims were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that home health claims require a TOB and FIPS code. We looked at the file and Medicare rules. The claims were not billed with a valid TOB and FIPS code. 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 pay for the home health services rendered from December 3, 2019 to December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation (D0367).
You asked the Plan to pre-approve the cone beam CT capture and interpretation. You say that you are not able to pay for the CT scan and were hoping that the dental plan would cover this. The Plan denied your request. The Plan says this 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. 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 cone beam CT capture and interpretation (D0367).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan provided on December 26, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that this was a post-cancer scan that your doctor ordered. You say insurance should be covering this. 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 $275 copayment for each advanced imaging service (e.g., MRI, CT and PET scan, nuclear medicine, and stress tests). You have been asked to pay a $275 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for the CT scan provided on December 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the outpatient clinic visits and laboratory services provided on November 7, 2019, November 12, 2019 and November 20, 2019.
You asked the Plan to waive the cost share for the outpatient clinic visits and laboratory services. You say that you were informed you only pay a deductible when you go to the hospital for surgery. You say that this is wrong. The Plan denied your request. The Plan says the cost share applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $500, which applies to all items and services except those specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Outpatient clinic visits are not excluded from the deductible. Your contract with the Plan says that you must pay a $40 copayment for lab services at an in-network outpatient hospital. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $500 deductible applies to outpatient clinic visits. This cost sharing is a contractual obligation that had not been met at the time the outpatient clinic was received on November 7, 2019 and November 20, 2019. Therefore, $244 was applied to the deductible.
Since laboratory services do not apply the deductible, you have also been asked to pay $23.37, which is less than the standard $40 copayment. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and 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 cost share for the outpatient clinic visits and laboratory services provided on November 7, 2019, November 12, 2019 and November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided to the enrollee by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. The Plan denied your request. The Plan says the plan has qualified specialists available within the plan.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve medical services to be provided to the enrollee by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve vascular services. You say that you are requesting approval based on a plan of care established. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider.
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 the medical services to be provided by an out of network (OON) provider.