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

We decided that the Plan does not have to pay forthe panoramic x-ray (D0330), the surgical extractions (D7210) of teeth # 25 and 26, the alveoloplasty in conjunction with extractions (D7311), and the unspecified oral surgery service (D7999 x 2) provided on October 10, 2019.You asked the Plan to pay forthe panoramic x-ray, the surgical extractions, the alveoloplasty in conjunction with extractions, and the unspecified oral surgery services. You say that the provider advised the extractions would cost $406 for you and they would bill the plan for $185. You say that the charges on your bill are fraudulent. You say that you did not receive an alveoloplasty, nor did you receivesurgical irrigation.The Plan denied your request. The Plan says the dental services you received are not covered services.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 dental services you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe panoramic x-ray (D0330), the surgical extractions (D7210) of teeth # 25 and 26, the alveoloplasty in conjunction withextractions (D7311), and the unspecified oral surgery service (D7999 x 2) provided on October 10, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Supartz FX injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that it is not known if there has been a trial and failure of three months of conservative therapy.
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 the injection. Our reviewer says that the requested injection is medically reasonable and necessary. Our physician reviewer found in this case the enrollee has received a steroid injection to the right knee and has been started on medical therapy (Duloxetine) for knee pain. The review has determined that the enrollee does have an indication for this injection. 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 injection have been met. Therefore, we decided that the Plan has to pre-approve Supartz FX injection for the enrollee.
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 pay for incontinence supplies.You asked the Plan to pay for incontinence supplies. You say that you received a denial notice for the purchased supplies. You say that your primary care doctor requested the supplies for you.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pay forincontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 16,2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.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 andpre-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 noexception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bitewing x-rays provided on November 5, 2019.You asked the Plan to pay forthe dental x-rays. You say that your dentist didn't do anything but refer you to a specialist.The Plan denied your request. The Plan says this request exceeds the benefitlimitation of one set a year.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The plan says that bitewing x-raysare covered once a year. The records show you received this service on April 25, 2019.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 at this time.Therefore, we decided that the Plan does not have to pay forthe bitewing x-rays provided on November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on September 5, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that the patient only provided traditional Medicare coverage for the dates of service. Please reprocess for payment for services rendered as the claim cannot be considered by traditional Medicare because the patient has coverage through the the plan. You were unaware of this at the time of service.The Plan denied your request. The Plan says even though provider indicates in the medical record, it was an urgent visit, the service rendered was a regular visit at the office and not rendered in an urgent clinic or emergency room. Also,the diagnosis submitted did not justify urgent oremergency services at an outpatient office place of service, outside of coverage area.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 exceptionthat would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foran office visit (99213) provided on September 5, 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 copayment for the spine injection provided on December 11, 2019.
You asked the Plan to waive the copayment for the spine injection. You say that the injection was done in the doctor's office. You say that you were not informed of the charge. 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 $300 copayment for Medicare-covered outpatient hospital services. You have been asked to pay a $300 copayment for the spine injection. The spine injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the spine injection was billed by the 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 spine injection provided on December 11, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc-One injection for the enrollee.You asked the Plan to pre-approve Synvisc-One. You say that this is medically necessary.The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Synvisc-One. Our reviewer says that Synvisc-One is not medically reasonable and necessary for the enrollee in this case. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found the enrollee's condition does not meet step therapy criteria for Synvisc-One.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met.Therefore, we decided that the Plan does not have to pre-approve a Synvisc-One injection for the enrollee
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on October 7, 2019 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that your provider depends upon the hospital staff to verify eligibility and obtain the proper authorization for in-network and out of network providers from the enrollee's insurance. You also say that your provider rendered medically necessary services to the enrollee in good faith. The Plan denied your request. The Plan says the rendering provider is a non-participating provider. The Plan also says that prior authorization was not obtained as required under the Plan benefits.
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 the subsequent nursing facility care provided on October 7, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 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 atissue. 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 August 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on May 2, 2019 and billed under codes 80307 and G0482.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the records provided do not support the services billed.
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on May 2, 2019 and billed under codes 80307 and G0482.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SFN) services provided on April 18, 2019 to May 17, 2019.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF services. The Plan denied your request. The Plan says medical necessity cannot be established for SNF level of coverage.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SFN) services provided on April 18, 2019 to May 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
You asked the Plan to pre-approve the dental services. You say that the enrollee has bite issues with current dentures. You also say that her top denture causes her to gag. The Plan denied your request. The Plan says dentures are covered every once every 5 plan years. The Plan also says that the frequency limit for dentures has been reached.
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 and dentures are a covered service, the frequency limit has been reached. The record shows that the Plan previously paid for dentures that the enrollee received on November 26, 2018. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Buspirone Hcl for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee is doing well on his current medications. The Plan denied your request. The Plan says that this medication is not covered under Part B.
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 Buspirone Hcl for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia services rendered to you on October 23, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99100 is not separately payable.The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.We looked at the file and Medicare rules. The provider submitted a claim for procedure code 99100 (special anesthesia service). This code has a status indicator of B and no separate Medicare payment. Payment for this code is included in another billed service.Therefore, we decided that the Plan does not have to pay forthe special anesthesia services rendered to you on October 23, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe upper GI endoscopy provided on November 22, 2019.You asked the Plan to waive the copayment forthe upper GI endoscopy. You say that you do not believe that the $400 copayment is justified because the endoscopy showed that no biopsy or further testing is needed. 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 $400 copayment for Medicare-covered in-network outpatient hospital surgery services. You have been asked to pay a $400 copayment for the upper GI endoscopy. The upper GI endoscopy falls within the Medicare-covered in-network outpatient hospital surgery "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the upper GI endoscopy is considered a surgical procedure.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 Plandoes not have to waive the copayment forthe upper GI endoscopy provided on November 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe lift chair sales tax for the chair purchased on May 27, 2019.You asked the Planto reimburse you forthe lift chair sales tax. You say that the lift chair is medically necessary.The Plan denied your request. The Plan says they will reimburse you for the lift chair at the Medicare approved payment rate less any coinsurance and/or copays but not the sales tax.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare does not reimburse sales tax separately.Therefore, we decided that the Plan does not have to reimburse you forthe lift chair sales tax for the chair purchased on May 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not haveto pay formethylprednisolone acetate (J1030x2) provided on September 27, 2019.You asked the Plan to pay forthe methylprednisolone acetate. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the submitted medical record does not indicate that 2 units of Injection, methylprednisolone acetate, 40 mg were administered.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 asked our coder 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 methylprednisolone acetate. Our reviewer says that CPT code J1030x2 does not meet criteria for reimbursement consideration. Our reviewer found the medical records provided do not include documentation of Injection, methylprednisolone acetate, 40 mg (2 units), therefore, the services cannot be verified. The medical records indicate that 1 unit of the drug was administered.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the methylprednisolone acetate have notbeen met.Therefore, we decided that the Plan does not have to pay formethylprednisolone acetate (J1030x2) provided on September 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided to enrollee on June 4, 2019.You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the documentation did not include a valid order or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that providers must produce medical records showing why the lab services provided were medically necessary.We looked at the file and Medicare rules. There were insufficient records that show the tests were needed to identify specific substances that were inadequately detected by a presumptive drug test. There is no evidence that shows the test was individualized to identify 15-21 specific non-prescribed medications or illicit substances. The records provided do not document concerns based on clinical review and judgement.Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided to enrollee on June 4, 2019.