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

We decided that the Plan does not have to pay for the laboratory services rendered on June 20, 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 laboratory services rendered on June 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a standard level hearing aid.  You asked the Plan to waive the copayment. You say that you are unable to afford the copayment for the hearing aid. The Plan denied your request. The Plan says copayments are a fixed amount that the member is responsible for, which cannot be waived or reduced.
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 $250 copayment for a standard level hearing aid. You have been asked to pay a $250 copayment for one standard level hearing aid ($250 x 1) to be provided.  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 standard level hearing aid.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided on June 12, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided on June 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided to you by an out-of-network provider on May 8, 2019.You asked the Plan to pay forthe lab services. The Plan denied your request. ThePlan says the provider directed you to "the lab". Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did notpre-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 forthe lab services provided to you by an out-of-network provider on May 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on August 6, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you were hospitalized and were not seen on the date of service. 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 $25 copayment for each in-network primary care doctor visit for Medicare-covered benefits. You have been asked to pay a $25 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The medical record shows you were seen for a hospitalization follow-up on August 6, 2019.
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 office visit provided on August 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from July 25, 2019 to October 13, 2019.You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not includethe carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from July 25, 2019 to October 13, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and consultation (99214 and 99243) provided on August 6, 2019 through August 21, 2019.You asked the Plan to pay for the office visit and consultation. You say that you do not believe that you should have to take on a new doctor because your preferred providers have opted out of Medicare. The Plan denied your request. The Plan says the service obtained was rendered by a provider that does not accept Medicare assignment.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation. These providers have opted out of the Medicare program. The file shows that the physicians entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the office visit and consultation (99214 and 99243) provided on August 6, 2019 through August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for 30 minutes of advance care planning services provided on May 13, 2019.You asked the Plan to pay for the advance care planning. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted medical records did not indicate that advance care planning first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate was performed.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 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.We find that CPT code 99497 is not supported in the medical record. Specifically, the record does not indicate that 30 minutes of advance care planning was rendered. Based on this information, we decided that Medicare rules for coverage of the advance care planning have not been met. Therefore, we decided that the Plandoes not have to pay for 30 minutes of advance care planning services provided on May 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rocklatan drops.You asked the Plan to pre-approve self-administered drugs. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits. The Plan also says that the enrollee's Medicare Part D prescription drug benefits may be administered by Express Scripts.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 Rocklatan drops.Benefits for self-administered drugsmaybe available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea (J0178).You asked the Plan to pre-approve Eylea. You say that this is medically necessary.The Plan denied your request. The Plan says the enrolleehas not tried and failed bevacizumab (Avastin) as required by step therapy rules.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 Eylea. Our reviewer says that the criteria for coverage of Eylea have not been met. Our physician reviewer found the Plan requires a trial of bevacizumab (Avastin) before they will approve the requested drug. The provided medical records do not indicate that the patient has tried and failed the required drug or that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea have not been met.Therefore, we decided that the Plan does not have to pre-approveEylea (J0178).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown (D2750), and the corebuildup (D2950).You asked the Plan to pre-approvethe dental services. The Plan denied your request. The Plan says the requested dental services are not listed as covered. The Plan also says that the provider is not a participating provider.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 comprehensive dental services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe crown (D2750), and the core buildup (D2950)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (code D5110), complete mandibular denture (code D5120), alveoloplasty in conjunction with extractions (code D7310 x4), reline complete maxillary denture (code D5730), reline complete mandibular denture (code D5731), reline complete maxillary denture (laboratory) (code D5750), reline complete mandibular denture (laboratory) (code D5751), removal of torus palatinus (code D7472), and removal of torus mandibularis (code D7473).You asked the Plan to pre-approvethe complete maxillary and mandibular dentures, alveoloplasties, reline complete maxillary and mandibular dentures (chair), reline complete maxillary and mandibular dentures (laboratory), and removal of torus palatinus and mandibularis. You say that the enrollee is on a fixed income and needs help from her dental insurance to get this treatment done. You also say that the enrollee is in pain.The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea complete maxillary denture (code D5110), complete mandibular denture (code D5120), alveoloplasty inconjunction with extractions (code D7310 x4), reline complete maxillary denture (code D5730), reline complete mandibular denture (code D5731), reline complete maxillary denture (laboratory) (code D5750), reline complete mandibular denture (laboratory) (code D5751), removal of torus palatinus (code D7472), and removal of torus mandibularis (code D7473).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the mental health services provided on July 10, 2019.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says an incorrect revenue code was reported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.In this case, the CPT Code Manual definition of code G0469 is Federally qualified health center (FQHC) visit, mental health, new patient; a medically-necessary, face-to-face mental health encounter (one-on-one) between a new patient and a fqhc practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving a mental health visit.We looked at the file and the rules. The records show that the claim was submitted with a revenue code 0521. The rules say that FQHC code G0469 must be reported under revenue code 0900 or 0519.Based on this information, we decided that Medicare rules for coverage of the services provided have not been met.Therefore, we decided that the Plan does not have to pay forthe mental health services provided on July 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from June 12, 2019 to August 31, 2019.You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DME POS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan madeseveral attempts to obtain theproof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from June 12, 2019 to August 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe technical component of the electromyography (EMG) testing provided on May 16, 2019.You asked the Planto pay forthe TC of the EMG testing. You say that this testing is medically necessary and should be paid.The Plandenied your request. The Plansaysthis claim was billed with a POS code of 15 which is not appropriate. This service was provided to a hospital inpatient. As such, the inpatient POS code should be reported.The Plan must follow Medicare rules. Medicare rules say that that mobile unit services should only report the POS code 15 if the mobile unit is servicing a location for which another POS code does not already exist.In this case, the services were provided to the enrollee during an inpatient hospital stay. This means that POS code 15 is not appropriate. The claim is not correctly billed.Therefore, we decided that the Plandoes not haveto pay forthe technical component of the electromyography (EMG) testing provided on May 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does nothave to pre-approvethe porcelain or ceramic crown for tooth #9.You asked the Plan to pre-approvethe crown for tooth #9. You say that the enclosed photograph taken November 2, 2019 annotates the amount of recession on the front teeth. You also say that the Class V composite restoration is not subgingival, nor does any decay progress subgingivally.The Plan denied your request. The Plansays the x-ray of the enrollee's tooth shows that there is a cavity below the bone of the tooth. The Plan also says that the service 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 the crown for tooth #9 when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the casefile and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the crown for tooth #9. Our reviewer says that the service is not medically necessary. Our physician reviewer found a supplied intra-oralphoto confirms the provider's statement that the gingival recession makes the x-ray appear as if the decay is below the level of the bone where in fact it is not. Our reviewer found that the need for a crown must be assessed. Our physician reviewer found that tooth #9 has existing mesial and distal restorations along with a large facial restoration. Our reviewer found that the incisal edge is essentially intact and it is not established that the tooth requires the support of a crown restoration. Our physician reviewer also found that as the incisal edge is 
essentially intact and the missing or damaged structure is less than 50%, there is no medical necessity for the requested procedure.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 for tooth #9 have not been met.Therefore, we decided that the Plan does not have to pre-approvethe porcelain or ceramic crown for tooth #9.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 7, 2019 to October 26, 2019.
You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 7, 2019 to October 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory work provided on August 27, 2019.You asked the Plan to waive the copayment forthe laboratory work. You say that you should not be responsible for the copayment because the follow up appointment to discuss the lab results was cancelled. 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 thatyou must pay a $40 copayment for each Medicare-covered laboratory test in an in-network outpatient hospital facility. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $40 copayment for the laboratory work.You have been asked to pay a $23.99 copayment for the laboratory work. The laboratory work 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 waive the copayment forthe laboratory workprovided on August 27, 2019.