Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection procedure provided at an outpatient hospital facility on December 12, 2019.
You asked the Plan to waive the copayment for an injection procedure. You say that you disagree with the charges. 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 outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received an injection procedure at an outpatient hospital facility on December 12, 2019. An injection procedure is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $325 copayment. You have been asked to pay a $325 copayment for an injection procedure. An injection procedure falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an injection procedure provided at an outpatient hospital facility on December 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve white glass metal caps for bridges (D6751) on teeth 2, 4, 29, and 32, false teeth for bridges (D6241) on 3, 30, and 31, and a crown (D2751) for tooth 8.
You asked the Plan to pre-approve white glass metal caps for bridges on teeth 2, 4, 29, and 32, false teeth for bridges on teeth 3, 30, and 31, and a crown (D2751) for tooth 8. You say that these services are necessary because you need to eat. The Plan denied your request. The Plan says the bridges requested do not meet the Plan's coverage rules and the crown is not medically necessary.
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 covers white glass metal caps for bridges on teeth 2, 4, 29, and 32, false teeth for bridges on teeth 3, 30, and 31, and a crown (D2751) for tooth 8 when the services are medically necessary and reasonable under the guidelines listed above. 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 white glass metal caps for bridges on teeth 2, 4, 29, and 32, false teeth for bridges on teeth 3, 30, and 31, and a crown (D2751) for tooth 8. Our reviewer says that the requested services do not meet the criteria for coverage. Our physician reviewer found the rules for coverage for a fixed bridge indicate that coverage is available for a fixed bridge replacing one maxillary anterior tooth or two mandibular anterior teeth and if no posterior teeth are missing. In this case the missing teeth to be replaced (2, 30 and 31) are posterior teeth. Coverage for a crown requires that a significant portion of the coronal structure is missing due to caries or fracture. The documentation provided does not show that tooth 8 has significant coronal breakdown.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of white glass metal caps for bridges on teeth 2, 4, 29, and 32, false teeth for bridges on teeth 3, 30, and 31, and a crown (D2751) for tooth 8 have not been met. Therefore, we decided that the Plan does not have to pre-approve white glass metal caps for bridges (D6751) on teeth 2, 4, 29, and 32, false teeth for bridges (D6241) on 3, 30, and 31, and a crown (D2751) for tooth 8.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger coded 99190 provided on November 12, 2019.
You asked the Plan to pay for assembly and operation of pump with oxygenator or heat exchanger. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99190 is assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour. We find that CPT code 99190 is not supported in the medical record. Specifically, the enrollee was inpatient during these services. Therefore, payment for this service would be included in the Part A DRG payment to the facility. Based on this information, we decided that Medicare rules for coverage of assembly and operation of pump with oxygenator or heat exchanger have not been met. Therefore, we decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger coded 99190 provided on November 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for placement of a breast localization device (19281LT) provided on November 22, 2019.
You asked the Plan to waive the copayment for placement of a breast localization device. You say that you should not be responsible for the copayment since you were not told in advance you would have to go to another location for this procedure to be done. If you had known, you would have gone to a location that could provide all the services at one time. 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 $15 copayment for diagnostic radiology services. You have been asked to pay $15 for placement of a breast localization device. 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 placement of a breast localization device (19281LT) provided on November 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Crestor.
You asked the Plan to pre-approve Crestor. You say that you have tried and failed alternative medication. The Plan denied your request. The Plan says your medical plan does not cover outpatient prescription drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Crestor.
Benefits for Crestor 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 18, 2019 to the enrollee by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without 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 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 medical services provided on October 18, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says your needs are custodial.
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 pre-approve SNF services. Our physician reviewer found that from a nursing perspective, you had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a standby assist to independent level with functional mobility. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on November 6, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that you have never had to pay before. 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 $10 copayment per visit for laboratory tests. You have been asked to pay a $10 copayment for laboratory services. 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 copayment for laboratory services provided on November 6, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health nursing visits.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the skills of the nurse are not needed for general health assessment and medication management.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 requested services. Our physician reviewer found that there are no ongoing skilled nursing needs. You are not receiving IV medications or fluids. Routine monitoring of your chronic medical conditions is being done such as assessment of pain, routine administration of oral medications, and support of chronic physical debilities. There are no unaddressed medical conditions or conditions that require complex monitoring or medication adjustments. Therefore, skilled therapy services are not required to effectively provide treatment, care, and/or services which are medically 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health nursing visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on November 7, 2019 to November 14, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on November 7, 2019 to November 14, 2019.
Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for enrollee.You asked the Plan to pre-approve the requested device. You say that the enrollee has tremors, which makes it difficult for her to check her blood sugar and give herself injections.The Plan denied your request. The Plan says coverage criteria have not been met.The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors are 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 the requested device. Our physician reviewer found that the enrollee is noted to be a diabetic. How often the enrollee checks her blood glucose is unclear, but it appears to be once a day. The enrollee is noted to take both a long-acting insulin and an oral medication for her diabetes. How often the enrollee takes the insulin is unclear, but it appears to be once or twice a day. There is no evidence that the enrollee uses the results of multiple-times-a-day blood glucose testing to adjust the dosage of her insulin. As such, the requested CGM is not shown to be medically necessary or reasonable.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 requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 19, 2019 the enrollee by a non-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without 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 referring provider 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 medical services provided on November 19, 2019 to the enrollee by a non-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nursing facility care (99309) provided on October 4, 2019 to October 16, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe physician services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not emergent or pre-authorized. There were network providers available.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says thatthe 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 forthe nursing facility care (99309) provided on October 4, 2019 to October 16, 2019 by an out of network (OON) provider,
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the x-ray provided on December 18, 2019.
You asked the Plan to reduce the copayment for the x-ray. You say that you were incorrectly billed. You say you should only be responsible for $35.21. 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 $50 copayment for each basic imaging service (e.g., general x-rays or ultrasound). You have been asked to pay a $50 copayment for the x-ray. The x-ray falls 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 reduce the copayment for the x-ray provided on December 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the endodontic treatment on tooth #19 (D3330).
You asked the Plan to pre-approve the endodontic treatment on tooth #19 (D3330). You say that your doctor has suggested a root canal/crown/cleaning root. You say you would like the service approved because you do not want the tooth removed. The Plan denied your request. The Plan says the services are not covered 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 endodontic treatment on tooth #19 (D3330) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the endodontic treatment on tooth #19 (D3330).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on November 5, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99053 is not supported.
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 99053 (Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service). This code has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the services rendered on November 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction of tooth #10 (D7210) or the maxillary partial denture (D5820) provided on April 1, 2019 and April 6, 2019.
You asked the Plan to pay for the extraction of tooth #10 (D7210) and the maxillary partial denture (D5820). You say that the services should be covered as they were necessary as the result of an accident. The Plan denied your request. The Plan says the services are not covered 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 extraction of tooth #10 (D7210) and the maxillary partial denture (D5820) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction of tooth #10 (D7210) and a maxillary partial denture (D5820) on April 1, 2019 and April 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testosterone cypionate injections.
You asked the Plan to pre-approve Testosterone cypionate injections. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Testosterone cypionate is not covered under the enrollee's Medicare Part B benefit.
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 Testosterone cypionate injections.
Benefits for Testosterone cypionate injections 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure.
You asked the Plan to pre-approve Ensure. You say that you need this because abnormal weight loss. The Plan denied your request. The Plan says that enteral nutrition products that are administered orally and related supplies are noncovered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan does not have to pre-approve Ensure.