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

We decided that the Plan does not have to pay for physician's services providedon October 29, 2019.You asked the Plan to pay for the physician's 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 is not a network provider with the Plan. The Plan did not pre-approve the services at issue. 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 physician's services provided on October 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for implant removal, by report (D6100) provided on January 30, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you did not know what was covered before the procedure occurred. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for implant removal, by report (D6100) provided on January 30, 2020 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous passive motion exercise device.
You asked the Plan to pre-approve a continuous passive motion exercise device (E0936). You say that the
enrollee needs a continuous passive motion exercise device post shoulder surgery. The Plan denied your
request. The Plan says Medicare guidance says that stretching machines used for the shoulders is not covered.
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have
received total knee replacement surgery.
The enrollee has not had total knee replacement surgery. Therefore, we decided that the Plan does not have to
pre-approve a continuous passive motion exercise device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 81542 provided on January 14, 2020.
You asked the Plan to pay for CPT code 81542. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. CPT code 81542 has a status code of "X" under the MPFSDB and represents a service that is not in the statutory definition of "physician services" for fee schedule payment purposes. Based on this information, we decided that Medicare rules for coverage of CPT code 81542 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 81542 provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electric stimulation therapy (97014), the office visit (99203), and the hot or cold packs therapy (97010) provided January 31, 2020 to February 24, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the electric stimulation therapy (97014), the office visit (99203), and the hot or cold packs therapy (97010) provided January 31, 2020 to February 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xalatan eye drops.
You asked the Plan to pre-approve Xalatan. You say that the enrollee has shown stable intraocular pressure for years on Xalatan. The Plan denied your request. The Plan says the drug is not covered under the Part B plan for the enrollee's condition.
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 Xalatan eye drops.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 13, 2020.You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support a valid order for the tests billed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, we decided that the Plan does not have to pay for drug testing provided on January 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate services.
You asked the Plan to pre-approve bone marrow aspirate services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 bone marrow aspirate services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee requires spinal fusion surgery. Bone marrow aspirate remains experimental for use in spinal fusion surgery. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspirate services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based composite - three surfaces, anterior (D2332 x 3) and resin-based composite - four or more surfaces or involving incisal angle (anterior) (D2335) provided on September 30, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
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. Medicare does not cover routine dental services and your plan already paid for four (4) filling procedures in 2019, prior to September 30, 2019. Your Plan supplemental dental benefit provides coverage for 4 fillings per calendar year. Therefore, we decided that the Plan does not have to pay for resin-based composite - three surfaces, anterior (D2332 x 3) and resin-based composite - four or more surfaces or involving incisal angle (anterior) (D2335) provided on September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from January 21, 2020 to February 19, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you 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 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 service at issue. 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 physician's services provided from January 21, 2020 to February 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on January 8, 2020.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 services at issue. 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 diagnostic radiology services provided on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided to the enrollee on October 30, 2019.
You asked the Plan to waive the copayment for outpatient hospital services. You say that you are appealing the cost-share and for coverage of oral surgery performed on October 30, 2019, stating that the enrollee is being balanced billed by the provider. The Plan denied your request. The Plan says the claim was processed accordingly with the enrollee's 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that the enrollee received outpatient hospital services on October 30, 2019. The enrollee is asked to pay a $300 copayment for the outpatient hospital services. 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 copayment for outpatient hospital services provided to the enrollee on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea hydrogen breath test.You asked the Plan to pre-approvethe requested services. You say that a breathtest is needed for a possible diagnosis of small intestinal bacterial overgrowth.The Plan denied your request. The Plan says there is no indication for a breath test for abdominal pain and inflammation of the large intestine.The Plan must follow Medicare rules. Medicare rules say that a diagnostic breath analyses is only covered under certain medical indications.We looked at the file and Medicare rules. Lactulose breath hydrogen for diagnosing small bowel bacterial overgrowth and measuring small bowel transit time is excluded from coverage. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approvea hydrogen breath test.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.
You asked the Plan to pre-approve Eliquis. You say that you need medication for a blood thinner. The Plan denied your request. The Plan says your Medicare Advantage 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 Eliquis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bone graft at time of implant placement (D6104) provided on February 27, 2020.You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the service is not a covered benefit under the plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it is not covered.Therefore, we decided that the Plan does not have to pay for bone graft at time of implant placement (D6104) provided on February 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forSNF care from December 5, 2019 through December 15, 2019.You asked the Plan to waive the copayment forSNF care. You say that the copayment is not fair because they gave you the wrong dosage of your medication at the nursing facility.The Plan denied your request. The Plan says vThe rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on December 5, 2019 and discharged on December 15, 2019. You were asked to pay a $200 copayment per day from December 5, 2019 through December 14, 2019, days 1-10 of your SNF care. You were discharged on December 15, 2019 and there was no copayment charge for the day of discharge. Per your contract thereis a $20 copayment per day required for days 1-20 of SNF care. 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 forSNF care from December 5, 2019 through December 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Part B drugs and intravenous infusions provided on November 5, 2019 to November 12, 2019.
You asked the Plan to waive the cost share for the Part B drugs and the intravenous infusions. You say that you were told that the hospital was overcharging you. 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 20% coinsurance for Medicare Part B-covered chemotherapy drugs and other Medicare Part B-covered drugs (including certain drugs that are used with nebulizers, insulin pumps, and IV infusion pumps) and a $250 copayment for each Medicare-covered outpatient hospital facility visit. You have been asked to pay $174.95 which is 20% of the allowed amount for the Part B drugs on each date of service. The allowed amount is $874.73. ($874.73 x 20% = $174.95). You have also been asked to pay $192.36, which is less than the standard copayment amounts for the intravenous infusions on each date of service. The Part B drugs fall within the "Medicare Part B prescription drugs" benefit category. The intravenous infusions fall 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 cost share for the Part B drugs and the intravenous infusions provided on November 5, 2019 to November 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forperiodic oral evaluation (D0120), bitewings -four radiographic images (D0274), prophylaxis -adult (D1110), resin-based composite -one surface, anterior (D2330) and resin-based composite -two surfaces, posterior (D2392) provided on February 6, 2020 and February 10, 2020 by out-of-network providers.You asked the Plan to pay forthe dental services. You say that it is misleading for the member as you think that your services would be paid at 100%.The Plan denied your request. The Plan says the claims were processed accordingly with your 2020 EOC 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.Review of the file show that you received the dental services on February 6, 2020 and February 10, 2020 from out-of-network providers. Your EOC states, providers are paid based on Maximum Allowable Charge (MAC). For services covered under the plan, you may still be billed by an out-of-network provider for any amount greater than the MAC payment madeby the plan to the provider.Therefore, we decided that the Plan does not have to pay forperiodic oral evaluation (D0120), bitewings -four radiographic images (D0274), prophylaxis -adult (D1110), resin-based composite -one surface, anterior (D2330) and resin-based composite -two surfaces, posterior (D2392) provided on February 6, 2020 and February 10, 2020 by out-of-network providers.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99212) provided on July 3, 2019.
You asked the Plan to pay for the office visit. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under the member's contractual policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99212) provided on July 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on January 16, 2020.You asked the Plan to pay forthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place.Therefore, we decided that the Plandoes not have to pay forthe laboratory services provided on January 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the custodial care services provided from March 17, 2019 to June 2, 2019.You asked the Plan to pay for the custodial care services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says custodial care is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that custodial care is not covered.We looked at the file and Medicare rules. The file shows that the services you received were not Medicare-covered home health aide services, but custodial services. The provider at issue provides only custodial care and homemaker services. Based on this information, we decided that Medicare rules for coverage of the custodial care services have not been met.Therefore, we decided that the Plan does not have to pay for the custodial care services provided from March17, 2019 to June 2, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has met their therapy goals, and additional visits are not necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records provided do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. He uses a recumbent exercise bike regularly and reportedly walks 1/4 mile before having increased pain. He has had 20 treatments of outpatient physical therapy already. Further physical therapy does not appear to be medically indicated at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued physical therapy services for the enrollee.