Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve INR home monitoring equipment to be provided at the in-network benefit level.
You asked the Plan to pre-approve the INR home monitoring equipment. You say that have been home testing since February 2017 and you would appreciate being able to continue with Alere because you find their products easy to use and you trust your results are accurate. The Plan denied your request. The Plan says these services are available in-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 when you receive care from an out-of-network provider you will be covered under your out-of-network benefit (POS). 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 has approved the services at the out-of-network POS benefit level. We found no exception that would require the Plan to pre-approve these services at the in-network benefit level. Therefore, we decided that the Plan does not have to pre-approve INR home monitoring equipment to be provided at the in-network benefit level.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the services from November 15, 2019 through November 18, 2019.
You asked the Plan to waive the copayment for the services. You say that you received a letter denying your inpatient stay. The Plan denied your request. The Plan says the claim was processed accordingly with your 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). When you were in the Emergency Room, a request was sent to the Plan for you to be admitted. This request was denied and the letter you mention was mailed to you. With the admission not being approved, the hospital kept you under observation as an alternative. The services were rendered in the outpatient hospital versus inpatient. You are asked to pay a $250 copayment for the magnetic resonance imaging (MRI). 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 services from November 15, 2019 through November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation, including oral evaluation (D9310), and a sinus augmentation (D7951) to be provided by an oral surgeon.You asked the Plan to pre-approve the dental services. You say that it is medically necessary that you have these services done. You say that the affected area has sensitive tissue with nerves around it and if not done by the right person it may lead to an infection that can spread to the head. You also say that you are unable to proceed with dental treatment before having a sinus lift done.The Plan denied your request. The Plan says dental services must be performed by a participating general dentist.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, dental services must be performed by a participating general dentist in order to be covered.Therefore, we decided that the Plan does not have to pre-approve a consultation, including oral evaluation (D9310), and a sinus augmentation (D7951) to be provided by an oral surgeon.
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 you would like to see this doctor because you used the same doctor 15 years ago. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for specialty lens, bifocal (V2430), antireflective coating (V2750) and polycarbonate lens (V2784) provided November 21, 2019.

You asked the Plan to pay for the vision services. You say that your policy clearly states it covers up to $100 for eyeglasses every year. You cannot understand where there is a problem because the provider is supposed to be in the network. The Plan denied your request. The Plan says the benefit maximum allowed has been exceeded.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The plan says that the $100 eyewear benefit was paid and it was applied to code V2430. Therefore, you are responsible for the remaining costs. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for specialty lens, bifocal (V2430), antireflective coating (V2750) and polycarbonate lens (V2784) provided November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain fused to predominantly base metal crown (D2751) for tooth # 19. You asked the Plan to pre-approve the dental service. You say that you need a crown because the tooth broke all the way down to the gum. You say that the crown needs to be porcelain so it will not break and to avoid problems in the future. You also say that metal crowns tend to break. The Plan denied your request. The Plan says porcelain fused to predominantly base metal crown is not listed as a covered service. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested porcelain fused to predominantly base metal crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a porcelain fused to predominantly base metal crown (D2751) for tooth # 19.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam rendered to you on October 1, 2019.You asked the Plan to waive the copayment for these services. You say that you disagree with the charges.The Plan denied your request. The Plan says the claim was processed 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 $35 copayment for each in-network Medicare-covered vision services visit. Review of the file shows that you received an eye exam on October 1, 2019. You have been asked to pay a $35 copayment for these services. These services fall within the in-network Medicare-covered vision services visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the eye exam rendered to you on October 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a chest x-ray (71046) provided on
November 4, 2019.
You asked the Plan to waive the copayment for the chest x-ray. You say that you were not told that you would
be responsible for a copayment at the time of service. 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 $35
copayment for basic radiological services.
You have been asked to pay $28.09 (the allowed amount) for the chest x-ray. A chest x-ray falls within the
basic radiological 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 chest xray
(71046) provided on November 4, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided
to the enrollee from July 16, 2019 through July 30, 2019 and August 1, 2019 through August 31, 2019.
You asked the Plan to waive the copayment for SNF care. You say that the claim should be paid. The Plan
denied your request. The Plan says the enrollee exhausted their 100 days.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The member's 100 day SNF benefit is exhausted. Therefore, coverage is not available for dates of service July
16, 2019 through July 30, 2019 and August 1, 2019 through August 31, 2019. The Plan has covered 100 days
of SNF care.
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided
that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided to
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that the enrollee has lymphedema and requires the stockings. The Plan denied your request. The Plan says gradient compression stockings A6530 are non-covered when there is no qualifying wound.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6530 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral knee orthoses (L1833) provided to the enrollee on August 17, 2019.
You asked the Plan to pre-approve the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the medical records do not support this service.
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary]. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Healthcare Common Procedure Coding System (HCPCS) code L1833-RT -KX (1 Unit) remains not supported. The documentation submitted did not include a valid physician order or proof of delivery for the billed date of service. Of note, the provided Delivery Ticket is not dated; therefore, we are unable to determine when the member received the billed supplies. Therefore, the billed supply code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. This administrative review was performed by a Claim Review Specialist. During the course of the original investigation, a review was conducted of the submitted medical documentation for the date of service August 17, 2019. This review determined that the billed services were not supported. An appeal was submitted. The medical records submitted during the course of the original investigation and new documentation submitted on appeal was thoroughly reviewed. Therefore, we decided that the Plan does not have to pre-approve bilateral knee orthoses (L1833) provided to the enrollee on August 17, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy to treat esophageal cancer.
You asked the Plan to pre-approve proton beam therapy. The Plan denied your request. The Plan says the requested service is still being studied to see if the treatment is reasonable and necessary.
The Plan follows Medicare rules. Medicare rules say that proton beam therapy is only covered under certain medical indications. 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 proton beam therapy. Our physician reviewer found that for esophageal cancer, proton therapy is not likely to be medically necessary. There is a paucity of data to support its use, which would be supported for exceptional cases. While there are some dosimetric advantages, there are other dosimetric disadvantages. In this case, the potential dosimetric advantage does not appear to be clinically meaningful. The case file does not adequately document, using quantifiable dosimetric measures, that an IMRT or conventional 3D conformal plan would be unacceptable. As such, proton therapy is not considered medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy to treat esophageal cancer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power operated vehicle.You asked the Plan to pre-approvea scooter. You say that the enrollee needs a scooter.The Plandenied your request. The Plan says the file shows the enrolleewalkswith a prosthetic and use a manual wheelchair for short distances.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that the enrollee'scondition can be improved by a manual wheelchairor prosthetics. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approvea power operated vehicle
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the rituximab injection or waive the copayment for the injection administration provided on December 6, 2019.
You asked the Plan to waive the coinsurance for the rituximab injection and waive the copayment for the injection administration. The Plan denied your request. The Plan says that the claim processed 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 20% coinsurance for Medicare-covered Part B chemotherapy and prescription drugs and a $10 copayment for Medicare-covered outpatient hospital services. You have been asked to pay a 20% coinsurance for the rituximab injection and a $10 copayment for the injection administration. The rituximab injection falls within the Medicare-covered Part B chemotherapy and prescription drugs and the injection administration falls within the Medicare-covered outpatient hospital 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 coinsurance for the rituximab injection and waive the copayment for the injection administration provided on December 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper denture (D5110).You asked the Plan to pre-approvecomplete upper denture. You say that [Enter appellant's argument from appeal letter, e.g. "...you need SNF care."]The Plan denied your request. The Plan says this service is allowed once every 60 months (5 years). Records show that you received this service July 30, 2015. This benefit will not be eligible until July 30, 2020.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. Per page 66-67 of the health plan contract says immediate partial flexible removable dentures, fixed dentures and all associated services including temporary dentures, tissue conditioning and overdentures are not covered by the plan.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-approvecomplete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (98941) provided on October 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for chiropractic services. You say that these services should be considered in-network. The Plan denied your request. The Plan says these services were provided out of network without 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 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 chiropractic services (98941) provided on October 2, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genomic sequencing to be performed.You asked the Plan to pre-approve the genomic sequencing. The Plan denied your request. The Plan says the documentation does not indicate an emergent or urgent medical condition or the need of specialized services that are not available in the 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve genomic sequencing to be performed.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe Prolia injection and laboratory services provided on September 6, 2019.You asked the Plan to waive the cost share forthe Prolia injection and laboratory services. You say that you were told it would be covered. You say that you shouldn't have to pay thatmuch.The Plan denied your request. The Plan says the cost share applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% for each Medicare-covered Part B drug obtained in an in-network provider's office or outpatient setting and $35 per day, per in-network provider, for Medicare-covered lab services.You have been asked to pay a total of $246.21 for the Prolia injection and laboratory services. The Prolia injection falls within the "Medicare Part B prescription drugs" benefit category. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share forthe Prolia injection and laboratory services provided on September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner chair (E1399).
You asked the Plan to pre-approve the recliner chair. You say that your hips are bone on pain and causing you pain. You have a wheelchair and a cane to assist you getting around your residence. The recliner chair would assist easing the pain in both hips. The Plan denied your request. The Plan says this item is considered a convenience item and is not a covered benefit.
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 a recliner chair (E1399).