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

We decided that the Plan does not have to pay forextraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided on July 8, 2019 by an out-of-network provider.You asked the Plan to pay forthe dental services. You say that you were advised that you could use an out-of-network oral surgeon and that you would receive reimbursement for your tooth extraction.The Plan denied your request. The Plan says you were advised that a simple extraction (D7140) is covered at 50%. The Plan states that you did not question if surgical extraction services would be covered by the Plan. The Plan states that you were not provided any misinformation.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. Your EOC states, the Plan will cover 1 simple extraction per year.Therefore, we decided that the Plan does not have to pay forextraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided on July 8, 2019 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transport chair.
You asked the Plan to pre-approve a transport chair (E1038). You say that because of medical conditions the enrollee needs a transport chair. The Plan denied your request. The Plan says there is no clinical documentation that the enrollee cannot use a cane or walker or that there is adequate access in the home.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at this the file and Medicare rules. The record does not show the enroll has impaired ability with MRADLs, or the home provides adequate access for the use of the transport chair. There is no information about the caregiver. Based on this information, we decided that Medicare rules for coverage of a transport chair (E1038) have not been met. Therefore, we decided that the Plan does not have to pre-approve a transport chair.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services (CPT 87631) provided on March 9, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that this is not a Medicare-covered service.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan says that this service is not covered by Medicare according to LCA A57579. LCA A57579 does not indicate that the requested service or CPT code is non-covered. A57579 indicates that there are certain coding rules that must be met for coverage of CPT code 87631. The plan has not shown that the coding rules have not been followed. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the lab services (CPT 87631) provided on March 9, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a PCP visit (99204) provided on January 27, 2020.
You asked the Plan to waive the copayment for the PCP visit. You say that you would like reconsideration because you have been overcharged for your copayment. The Plan denied your request. The Plan says your contract with the Plan that you were with on this date of service states that you have a $25 copayment for each out-of-network primary care doctor visit.
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 for Physician/Practitioner services. You have been asked to pay a $25 copayment for the PCP visit. The PCP visit falls 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 copayment for a PCP visit (99204) provided on January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that the enrollee was taking the medication more often than recommended and now needs a refill of the drug in order to continue use. The Plan denied your request. The Plan says that the current information from the enrollee's prescriber shows normal amounts and/or dispensing intervals. The Plan says that the available covered amount appears to be adequate.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not provided us with valid medical records. Despite our attempts to obtain this necessary information the Plan has not supplied it. Without valid medical records, we cannot properly review whether or not the requested drug is medically necessary and the Plan has not substantiate their denial reason. Therefore, we decided that the Plan has to pre-approve Prolia.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea total electric hospital bed.You asked the Plan to pre-approvea total electric hospital bed. You say that a semi-electric hospital bed is dangerous but you could operate a total electric bed on your own.The Plan denied your request. The Plan says total electric hospital beds arespecifically excluded from coverage by Medicare.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approvea total electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder brace provided on February 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON shoulder brace. You say that you were on vacation and dislocated your shoulder and went to the nearest urgent care facility. The Plan denied your request. The Plan says there is no documentation of an urgent care visit for this time frame and there are network providers available who could have furnished this brace.
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. There is no clear evidence, such as medical records, to show that you were out of the Plan's service area and had an urgent need for this brace which could not be provided in-network. 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 shoulder brace provided on February 13, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided on November 7, 2019 and January 6, 2020.
You asked the Plan to waive the copayments for specialist visits. You say that you disagree with the charges because you receive help and should not have a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $50 copayment for specialist visits. The medical records show that you had specialists visits on November 7, 2019 and January 6, 2020. Therefore, you are responsible to pay $50 copayment per each visit. The total amount you owe is: $100. You have been asked to pay the total copayment amount of $100 for specialist visits. Specialist visits fall 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 copayments for specialist visits provided on November 7, 2019 and January 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for INR test materials provided on February 12, 2020, February 19, 2020, and February 26, 2020
You asked the Plan to pay for INR test materials. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the claims were billed as four separate tests less than 25 days.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that one unit of materials is for four tests. The materials should be billed once no less than 25 days from the previous claim. Based on this information, we decided that Medicare rules for coverage of INR test materials have not been met. Therefore, we decided that the Plan does not have to pay for INR test materials provided on February 12, 2020, February 19, 2020, and February 26, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on November 12, 2019 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you tried to obtained prior authorization and it was denied.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 whocan 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 forphysician services provided on November 12, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drugs you received on February 20, 2020.
You asked the Plan to waive the coinsurance. The Plan denied your request. The Plan says you are responsible for the cost share.
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 Medicare Part B drugs. Review of the file shows that you were provided Part B drugs on February 20, 2020. You have been asked to pay a 20% coinsurance for the drugs, $309.69. The drugs fall within the Medicare Part B drugs 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 Part B drugs you received on February 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300), an attendant control (E2331) and center mount footplate connector bracket (K0108). You asked the Plan to pre-approve these items. You say that you would medically benefit from these features.The Plan denied your request. The Plan says that these items are not covered.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. The rules also say that if an attendant control is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered.The file shows that you have a mounting bracket that comes with the provided footrest. A mounting bracket serves the same purpose as center mount footplate connector bracket (K0108). An attendant control cannot be covered in addition to the enrollee-operated device control system already approved by the plan.Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300), an attendant control (E2331) and center mount footplate connector bracket (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental implants.
You asked the Plan to pre-approve the dental implants. You say that you would like to have implants covered because you cannot wear regular dentures. Dentures make you gag. You are having medical issues because you do not have any teeth in your mouth. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the dental implants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sterile water (A4217).
You asked the Plan to pre-approve sterile water. You say that you need the sterile water for treatment of an open wound on your right lower leg. The Plan denied your request. The Plan says this item is a non-reusable, disposable supply item available in stores without a prescription.
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. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve sterile water (A4217).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cystourethroscopy provided on February 11, 2020.
You asked the Plan to waive the copayment for a cystourethroscopy. You say that you disagree with the charges because you had only paid about $50 in the past. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $325 copayment for hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $325 copayment for a cystourethroscopy. A cystourethroscopy falls within the 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 a cystourethroscopy provided on February 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe MyoPro myoelectric orthosis (L8702).You asked the Plan to pre-approvethe orthosis. You say that given that traditional rehab for her left arm and less sophisticated medical devices have been tried and failed, the enrollee has been referred for myoelectric orthotic restoration.The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approvethe MyoPro myoelectric orthosis (L8702).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assay of sex hormone binding globulin provided on February 28, 2020.You asked the Plan to pay forthe testing services. You say that the lab performed all the tests that were ordered by the referring physician.The Plan denied your request. The Plan says the testing is not a Medicare benefit for the diagnoses listed on the claim.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 documentation shows the test at issue in this appeal was provided for the diagnosis of essential hypertension. In this case, there were insufficient records provided to show the results of this testing would be used to determine a specific treatment strategy for the listed diagnosis. This testing is not covered for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay forthe assay of sex hormone binding globulin provided on February 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in shower stall with door.
You asked the Plan to pre-approve a walk-in shower stall with door. You say that you need a walk-in shower to prevent slips and falls trying to get into a tub. 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 walk-in shower stalls are not covered because they are not primarily medical in nature. While a walk-in shower stall may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Also, Medicare does not cover home modifications. Therefore, we decided that the Plan does not have to pre-approve a walk-in shower stall with door.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on January 31, 2020.
You asked the Plan to waive the copayment for the laboratory services. You say that you were told this service was not covered because you did not go to your primary care physician. 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 $35 copayment for laboratory services at an in-network outpatient hospital. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $35 copayment for the laboratory work.
You have been asked to pay a $4.29 copayment for the laboratory services. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed by an outpatient hospital.
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 laboratory services provided on January 31, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approvecontinued skilled nursing facility (SNF) services after June 2, 2020 for the enrollee.You asked the Plan to pre-approveSNF care. You say that the enrollee is having acute kidney failure and severe weakness.The Plan denied your request. The Plan says that that the enrollee is showing signs of improvement, can move in their bed, their wounds have healed and can get up with little to no help.The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before June 2, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued.Therefore, we decided that the Plan has to pre-approvecontinued skilled nursing facility (SNF) services after June 2, 2020 for the enrollee.