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

We decided that the Plan does not have to pre-approve health club membership
You asked the Plan to pre-approve health club membership. You say that your doctor feels it would help your osteopenia. You want to know why every other plan offered in your location includes this, even ones that do not charge an additional monthly fee, but this plan doesn't. The Plan denied your request. The Plan says this request is not covered under the plan benefits.
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. The services at issue in this appeal are gym benefits. Therefore, we decided that the Plan does not have to pre-approve health club membership.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the surgical extraction (D7210) provided on November 4, 2019 by an out of network provider.
You asked the Plan to waive the deductible for the dental service. You say that you believe that you met the deductible prior to receiving these services. The Plan denied your request. The Plan says there is $100 deductible that must be met before services can be paid. The Plan also says that the deductible does not apply to preventive or diagnostic dental 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 $100 deductible has not been met. The record shows that the services that you received in 2019 prior to November 4, 2019 were for preventive dental services. The Evidence of Coverage clearly states that the deductible does not apply to preventive or diagnostic dental services. Therefore, we decided that the Plan does not have to waive the deductible for the surgical extraction (D7210) provided on November 4, 2019 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided from September 23, 2019 to November 6, 2019.
You asked the Plan to pay for the drug 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 drug testing provided from September 23, 2019 to November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 8, 2019 to July 19, 2019 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 July 8, 2019 to July 19, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on November 16, 2019.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a diagnostic colonoscopy on the date of service at issue in this appeal. The Plan states the correct copayment has applied per your contract with the Plan.
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 $295 copayment for Outpatient surgery. A screening colonoscopy is a procedure done for a patient who has no symptoms of colon cancer. A diagnostic colonoscopy is done when a patient has related symptoms or has a polyp removed during the procedure. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a diagnostic colonoscopy on November 16, 2019. You have been asked to pay a $295 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the Outpatient surgery 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 diagnostic colonoscopy provided on November 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on October 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for pathology services. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no network deficiency for these services and alternate network providers were found.
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 pathology services provided on October 9, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 1, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on October 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown - Porcelain Fused To High Noble Metal for tooth #6 (D2750).
You asked the Plan to pre-approve the crown. You say that this request is medically necessary due to there being an open margin on the crown. The Plan denied your request. The Plan says replacement of the crown is not reasonable or necessary and does not meet the coverage criteria.
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 the crown when the services are medically necessary and reasonable. 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 crown. Our reviewer says that this request does not meet the medical necessary criteria Our physician reviewer found in this case, the endodontic filling on #6 is more than four millimeters short of the apex, which makes for a much higher risk of reinfection and worsens the long term prognosis of the tooth. Therefore, given the short endodontic fill, along with there being no obvious defect of the margin of the crown on #6, there would be no medical necessity for a new crown on tooth #6. If the crown is ever found to be failing due to decay, there would be a need to retreat the root canal of #6. 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 the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve the crown - Porcelain Fused To High Noble Metal for tooth #6 (D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 5, 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 physician's services. 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 November 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of an impacted tooth (D7240 x 3).
You asked the Plan to pre-approve these services. You say that the requested dental services are medically necessary. The Plan denied your request. The Plan says that the dental services are not a covered benefit under the enrollee's contractual policy.
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 services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of an impacted tooth (D7240 x 3).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the fistula revision (36832). You say that you would like reconsideration because this providers authorization should be included in the facilities authorization. The Plan denied your request. The Plan says this claim denied due to no prior authorization for outpatient 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 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 January 17, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder/arm orthosis provided on December 19, 2019.
You asked the Plan to pay for the shoulder/arm orthosis (L3960). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the documentation submitted did not support the diagnosis used on the submitted order or indicate the provider discussed the need for the billed supply code.
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. There are no records supporting medical necessity of the orthosis. Based on this information, we decided that Medicare rules for coverage of the shoulder/arm orthosis (L3960) have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder/arm orthosis provided on December 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you were unaware that prior authorization was required. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-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 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 lab work provided on December 19, 2019 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 Bose Hearphones Conversation Enhancing Headphones purchased on December 13, 2019.
You asked the Plan to pay for the headphones. You say that since these work as well as regular hearing aids at a fraction of the cost, they should be covered by the plan. The Plan denied your request. The Plan says that these headphones are available for purchase by the general public, without a doctor's order, at non-durable medical equipment supply companies.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the headphones are an OTC item. Therefore, we decided that the Plan does not have to pay for the Bose Hearphones Conversation Enhancing Headphones purchased on December 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an MRI provided on February 4, 2020.
You asked the Plan to pay for the MRI. The Plan denied your request. The Plan says that 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 an MRI provided on February 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for panoramic x-rays (D0330) provided December 12, 2019.
You asked the Plan to pay for the dental services. You say that you were told that you could go to this provider and is now you're receiving the denials that the provider is out of network. The Plan denied your request. The Plan says this service is not covered under the plan's benefits package.
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 health plan contract specifically states that any services not listed under the description of benefits is 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 pay for panoramic x-rays (D0330) provided December 12, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from October 4, 2019 to October 31, 2019.You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says type of bill 323 is not valid for Medicare Home Health.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information,we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was submitted with an invalid type of bill code.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from October 4, 2019 to October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on October 1, 2019.
You asked the Plan to pay for the nurse practitioner services. You say that the doctor's office told you they
accepted your health Plan. 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 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 nurse practitioner services provided on October 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 3 power wheelchair and attachments.You asked the Plan to pre-approvea Group 3 power wheelchair and attachments. The Plan denied your request. The Plan says that this is not medically necessary.The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:1. A neurological condition;2. Myopathy; or3. Congenital skeletal deformity.The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity.Therefore, we decided that the Plan does not have to pre-approvea Group 3 power wheelchair and attachments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora sacroiliac joint injection (27096) provided on July 24, 2019.You asked the Plan to pay forthe sacroiliac joint injection. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted did not support that the billed service was rendered on this date of service.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 27096 is injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed.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 sacroiliac joint injection. Our reviewer says that CPT code 27096 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of an injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed,being performed on July 24, 2019, therefore, this service cannot be verified.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 sacroiliac joint injection have not been met.Therefore, we decided that the Plan does not have to pay fora sacroiliac joint injection (27096) provided on July 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.You asked the Planto pre-approvethe home ventilator. You say that you feel that this is necessary for use in the home.The Plandenied your request. The Plansaysyou do not require this level of ventilation based on the records provided.The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.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 home ventilator. Our reviewer says that the requested ventilator is not considered medically reasonable and necessary. Our physician reviewer found this patient has diagnoses of asthma and COPD, but no pulmonary function data are provided for confirmation. There are no arterial blood gas data to show CO2 retention. There is no indication of hypoxemia. The patient does not have neuromuscular disease or thoracic restrictive disease. BiPAP has not been tried. The patient does not have a coverable diagnosis. Usage data do not meet minimum usage requirements. A home ventilator is not 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 home ventilator have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea home ventilator.