Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the corneal topography you received on November 25, 2019.
You asked the Plan to pay for the corneal topography. You say that the test was necessary to determine if any chances had occurred to his cornea. The Plan denied your request. The Plan says that the test is not medically necessary to detect or monitor diseases of the cornea.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 pay for the corneal topography. Our physician reviewer found that you had symptoms of blurred vision with multiple findings on examination that could explain the symptoms. In a situation such as this where there is corneal disease, previous corneal surgery, and multiple findings, testing with corneal topography is the standard of care and would be necessary to further diagnosis and guide treatment. Therefore, the corneal topography test was medically necessary in this case. 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 corneal topography have been met. Therefore, we decided that the Plan has to pay for the corneal topography you received on November 25, 2019.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a colonoscopy at a tertiary level.
You asked the Plan to pre-approve the colonoscopy. You say that this is medically necessary. The Plan denied
your request. The Plan says a tertiary level of care is not required, and care can be provided in a community
setting.
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 the colonoscopy. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the available records do not support nor meet provided coverage criteria for ongoing tertiary
care follow-up. Expertise is available at the community level in network.
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 colonoscopy have not been met. Therefore, we decided that the Plan does
not have to pre-approve a colonoscopy at a tertiary level.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 13, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for 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 who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by your chosen physician.
You asked the Plan to pre-approve the physician's services. You say that ten years ago this physician performed back surgery on you and the results that came from this surgery were a miracle. You say that you are having some of the familiar back pain again and you would like this physician to examine you and, if necessary, to perform the operation. The Plan denied your request. The Plan says the plan requires you to receive care from providers who are part of your primary care physician's (PCP) specialty 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 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 contract with the Plan also says that the plan requires the enrollee to receive care from providers who are part of the enrollee's primary care physician's (PCP) specialty network.
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 the requested services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by your chosen physician.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency department (ED) visit (99285) provided from November 1, 2019 to November 3, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that you should not be responsible for the copayment since you had originally been admitted to the hospital, but then were changed to observation status. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $75 copayment for each emergency room visit. You have been asked to pay $75 for the ED visit. 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 emergency department (ED) visit (99285) provided from November 1, 2019 to November 3, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for Train of Four monitoring (95999) provided on August 15,
2019.
You asked the Plan to pay for the Train of Four monitoring. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says Train of Four is considered a bundled
procedure and payment for it is included in payment for the already-approved neuromonitoring.
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 CPT code 95999 is not supported in the record. Specifically, Train of Four is considered integral
to the primary procedure and therefore is part of a bundled payment. Based on this information, we decided
that Medicare rules for coverage of the Train of Four monitoring have not been met. Therefore, we decided that
the Plan does not have to pay for Train of Four monitoring (95999) provided on August 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on September 3, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not covered.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on September 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital and surgical services provided from April 8, 2019 to April 24, 2019 in Mexico.
You asked the Plan to pay for the hospital care. You say that you were told that emergency surgery was covered outside of the US. The Plan denied your request. The Plan says Medicare does not cover services provided outside of the US. Your plan does not offer any supplemental benefit which covers more than what Medicare does.
The Plan must follow Medicare rules. Medicare rules say that services provided outside of the US are not covered. Your contract also indicates this coverage limitation. Although the services may have been appropriate, there is no coverage available for services provided outside of the US. Therefore, we decided that the Plan does not have to pay for the hospital and surgical services provided from April 8, 2019 to April 24, 2019 in Mexico.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ER services and inpatient stay provided from July 17,
2019 through July 29, 2019.
You asked the Plan to pay for the ER services and inpatient stay. You say that the enrollee was discharged from
Hospice prior to the services. You say that the claim should be reconsidered for payment. The Plan denied your
request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on July 2, 2019. The services in question were provided before
the end of that month. Therefore, we decided that the Plan does not have to pay for the ER services and
inpatient stay provided from July 17, 2019 through July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for audiology testing provided on December 4, 2019.
You asked the Plan to pay for the audiology testing. The Plan denied your request. The Plan says 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 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 audiology testing provided on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the urgent care center visit provided on December 1, 2019.
You asked the Plan to adjust the copayment for the urgent care services. You say that you feel that you should not have to pay more than the $30 specialist copayment for this visit. You say that you would have gone to the hospital if you knew there was a $50 copayment because the hospital does not charge copayments. The Plan denied your request. The Plan says you were correctly charged $50 for the urgent care visit.
Please note: Your emergency room copayment is $90 per 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 $50 copayment for urgent care center visits. You have been asked to pay a $50 copayment for the urgent care services. The urgent care services fall within the urgent care center 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 adjust the copayment for the urgent care center visit provided on December 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the abdomen.
You asked the Plan to pre-approve CT scan. You say that the enrollee never had the approved Magnetic Resonance Imaging (MRI) test. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because a similar study was already approved by the Plan and results of this study have not been provided to the Plan.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 CT scan. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested CT scan. Our physician reviewer found the Plan previously approved authorizations for Magnetic Resonance Imaging (MRI) of the abdomen and Magnetic Resonance Cholangiopancreatography (MRCP) which remain in effect. These tests would be the procedures of choice to evaluate the enrollee. If the clinician prefers CT of the abdomen in lieu of the already approved studies, then rationale for that should be explained to the Plan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the abdomen.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites (D2335) provided on October 22, 2019.
You asked the Plan to pay for the resin-based composites. You say that you told an insurance plan representative, two to three times, that you wanted the same coverage as your wife. You also say that you have paid the monthly deduction you owe since September 1, 2019. The Plan denied your request. The Plan says this service is not a covered benefit. The Plan also say their call records do not support that they were contacted by you or the provider's office to verify your benefits prior to the services being rendered.
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 two resin-based composites (D2335) provided on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on July 26, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that these services were provided in a skilled
nursing facility. You say that the facility is in charge of getting prior authorization. The Plan denied your
request. The Plan says no prior authorization was obtained for 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 who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for skilled nursing services provided on July 26, 2019
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit, duplex scan and endovenous ablation
therapy to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit, duplex scan and endovenous ablation therapy. You say that
these services are medically necessary. The Plan denied your request. The Plan says there are in-network
providers available for 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 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. Please contact the Plan for a list of in-network
providers. 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 an office visit, duplex scan and endovenous
ablation therapy to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewing x-rays, prophylaxis, and panoramic x-ray provided on October 1, 2019.
You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-rays, prophylaxis, and panoramic x-ray. You say that for the first cleaning of the year you were covered by another Plan. You also say that on the October 1, 2019 date of service, the dentist would not see you because you were not covered. The Plan denied your request. The Plan says the benefits for these services have been satisfied and the frequency limitation have been exceeded.
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, exams and prophylaxis are each limited to one procedure per calendar year, bitewing x-rays are limited to one set per calendar year, and full mouth or panoramic x-rays are limited to one procedure every five years. The record shows that you received a periodic oral evaluation, bitewing x-rays, and a prophylaxis on March 26, 2019 and your exams, bitewing x-rays, and prophylaxis benefits were then exhausted. The record also shows that you received a complete series of intraoral x-rays on September 19, 2018 and your full mouth or panoramic x-rays benefit is now exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewing x-rays, prophylaxis, and panoramic x-ray provided on October 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildups, including any pins when required
(D2950) for tooth #'s 23, 24, & 29.
You asked the Plan to pre-approve the core buildups. You say that composite restorations have failed multiple
times due to occlusal forces and the enrollee requested no fillings since it would not work. You also say that
due to the amount of teeth missing, buildup and crowns are necessary. The Plan denied your request. The Plan
says Medicare does not cover this service and therefore this service is not covered by the enrollee's Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core
buildups, including any pins when required (D2950) for tooth #'s 23, 24, & 29.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on October 22, 2019.
You asked the Plan to pay for drug test. 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 this service is correct, because the documentation submitted does not include a physician order, lab requisition, or medical records stating exactly which tests were to be performed.
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 test billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that this is the provider you have been seeing for a while. You say that you would like to continue to see this provider. The Plan denied your request. The Plan says there are in-network providers available for 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 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 an office visit to be provided by an out of network (OON) provider.