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

We decided that the Plan does not have to pre-approveAmitiza capsules.You asked the Plan to pre-approveAmitiza capsules. You say that you would like the Plan to reconsider their denial.The Plandenied your request. The Plan says Amitiza capsules are 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-approveAmitiza capsules.Benefits for Amitiza capsulesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with metastatic anal melanoma and diarrhea. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was treated for pain with effect. Regarding rehabilitation services, the enrollee received physical therapy in the acute hospital. The enrollee was at a contact guard assist level with functional mobility including gait to 125 feet with a rolling walker. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on March 17, 2020 by an out of network (OON) provider.You asked the Plan to pay forthese 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 had network providers available who could have provided 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 medical services provided on March 17, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-radiological diagnostic services provided by a participating provider on September 2, 2020.You asked the Planto waive the copayment for an EKG. You say that you haven't been charged for this before. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.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 $30 copayment for outpatient diagnostic tests/non-radiological diagnostic services. You have been asked to pay a $30 copayment for an EKG. An EKG falls within the outpatient diagnostic tests/non-radiological diagnostic services benefit category. This means that you have been asked to pay thecorrect 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 non-radiological diagnostic services provided by a participating provider on September 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (S9328) provided on April 15, 2020, through July 13, 2020.You asked the Plan to pay forthe home infusion therapy. You say that you would like reconsideration because this is not durable medical equipment and was not delivered to the member's home.The Plan denied your request. The Plan says this code is not recognized for non-contract providers.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy (S9328) provided on April 15, 2020, through July 13, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus xT gene panel rendered on December 19, 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 testing was not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that NGS is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the testing was not medically necessary. Our physician reviewer found the enrollee has metastatic epithelioid angiosarcoma. Treatment with Taxol began in October of 2019. The documentation does not support that the Tempus xT gene testing is cleared or approved by the FDA as a companion in vitro diagnostic, and has an FDA-approved of FDA-cleared indication for use in the enrollee's cancer. The testing was therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xT gene panel rendered on December 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on September 16, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for lab work. You say that prior authorization was not obtained. The Plan denied
your request. The Plan says prior authorization was not obtained.
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 had network providers
available who could have provided 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 September 16, 2020 by an
out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 21, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not approved in advance.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 had network providers available who could have provided the services at issue in this appeal. 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 forthe medical services provided to the enrollee by an out-of-network provider on September 21, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forperiodontal maintenance (D4910) provided on September 29, 2020.You asked the Plan to pay forperiodontal maintenance. You say that the service should be covered.The Plan denied your request. The Plan says you have exhausted your maximum 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 requested items or services are not among those covered under this benefit. Specifically, records indicated you have exceeded the $1,000 allowance for comprehensive dental services for the quarter. This means the service is not covered.Therefore, we decided that the Plan does not have to pay forperiodontal maintenance (D4910) provided on September 29, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran office visit provided on September 15, 2020.You asked the Plan to waive the copayment foran office visit. You say that this was your annual wellness exam and you should not be responsible for 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 $10 copayment for primary care provider visits.The medical records show that you received services beyond an annual wellness exam on September 15, 2020. Therefore,you are responsible to pay the $10 copayment.  You have been asked to pay a $10 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 foran office visit provided on September 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.
You asked the Plan to pre-approve Eliquis. The Plan denied your request. The Plan says this drug is not covered for your condition by your Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment forhearing services provided on September 14, 2020.You asked the Plan to waive the copayment forhearing services. You say that you feel that you should only owe a $30 copayment.The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $0 copayment for hearing services. The Plan says you must pay a $147.48 copayment for hearing services. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for hearing services.Therefore, we decided that the Plan has to waive the copayment forhearing services provided on September 14, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on August 25, 2020 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not obtained.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 had network providers available who could have provided 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 forphysician services provided on August 25, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe GeneSight testing rendered on July 24, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the criteria are not met.The Plan must follow Medicare rules. The rules say that GeneSight testing may only be ordered by licensed psychiatrists or neuropsychiatrists.We looked at the file and Medicare rules. The file shows that the testing was ordered by a family medicine physician. 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 forthe GeneSight testing rendered on July 24, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient mental health services rendered from June 10, 2020 to June 25, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the provider type is not covered.The Plan must follow Medicare rules. The rules say that a Licensed Professional Counselor is not eligible to participate in Medicare.We looked at the file and Medicare rules. The file shows that the providera Licensed Professional Counselor. 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 forthe outpatient mental health services rendered from June 10, 2020 to June 25, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve an apicoectomy (D3410) of tooth #8.
You asked the Plan to pre-approve the apicoectomy. You say that you are in pain, and have taken antibiotics.
You also say that you do not want your tooth to be infected again. The Plan denied your request. The Plan 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
apicoectomy 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 apicoectomy. Our reviewer says
that the criteria of medically reasonable and necessary have been met. Our physician reviewer found your
dental record and radiograph indicates a completed root canal on tooth #8 along with a post and crown. Our
reviewer found that you continue to have pain in the area. The reason may be due to incomplete
instrumentation and obturation of the root canal or an accessory canal(s) which were not evident. Our physician
reviewer also found that due to the fact of the presence of a post and crown on the tooth, an apicoectomy would
be reasonable and necessary to treat this rather than removal of the post and crown and redoing the root canal.
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 apicoectomy have been met. Therefore, we decided that the Plan has to pre-approve
an apicoectomy (D3410) of tooth #8.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 13, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says that all services obtained from out-of-network providers require prior authorization except for emergency or urgently needed services when the network is not available and out-of-area dialysis 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 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 subsequent nursing facility care provided on July 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal medicament carrier with peripheral seal provided on June 24, 2020.You asked the Plan to pay forthe periodontal medicament carrier. You say that this service was a medical procedure, and not a dental one.The Plan denied your request.The Plan says this service is dental in nature, and not a covered benefit under your dental 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 pay forthe periodontal medicament carrier with peripheral seal provided on June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foreyeglasses provided on June 18, 2020.You asked the Plan to pay foreyeglasses. You say that the service is medically necessary.The Plan denied your request. The Plan says you received the item from an out-of-network provider.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 provides a $40 allowance for you to use toward the purchase price of eyewear from a plan optical facility when a physician or optometrist prescribes an eyeglass or contact lens for vision correction.We looked at the file and the Plan's rules. Eyeglasses must be purchased from a Plan network provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Specifically, you did not receive the eyeglasses from a Plan network provider. This means the service is not covered.Therefore, we decided that the Plan does not have to pay foreyeglasses provided on June 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forlimited oral exam (D0140) provided on August 26, 2020.You asked the Plan to pay fororal exam. You say that the service was medically necessary.The Plan denied your request. The Plan says you have exceeded your Plan benefit for this 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 items or services are not among those covered under this benefit. Specifically, recordsshow you have already exhausted your two oral exams allowed for the 2020 calendar year. This means the service is not covered.Therefore, we decided that the Plan does not have to pay forlimited oral exam (D0140) provided on August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe oral evaluation (D0120), prophylaxis (D1110), and the complete series x-ray (D0210) provided on September 14, 2020.You asked the Plan to pay forthe dental services. You say that this provider is in network. You also say that you received a bill for $251.The Plan denied your request. The Plan says the complete series x-ray is not listed as a covered service. The Plan says the provider in this case is out of network. The Plan says that you pay a 50% coinsurance for dental services that you receive out of network. The Plan also says that you were advised of your plan benefits during a phone call on August 10, 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.Though the Plan offers a dental benefit in excess of Medicare coverage, the complete series x-ray is not among those covered under this benefit. Additionally, dental services that you receive out of network are subject to a higher cost share.Therefore, we decided that the Plan does not have to pay forthe oral evaluation (D0120), prophylaxis (D1110), and the complete series x-ray (D0210) provided on September 14, 2020