Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional acupuncture visits (97810).
You asked the Plan to pre-approve the acupuncture visits. You say that you are appealing the denial of the additional visits. The medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says this request exceeds the plan's maximum benefit limitation.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the plan only allows 20 routine acupuncture visits per calendar year. Therefore, we decided that the Plan does not have to pre-approve additional acupuncture visits (97810).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide routine transportation trips with additional mileage allowance.
You asked the Plan to provide routine transportation with additional mileage. You say that you need to see this doctor and feel that the mileage allowance should be increased in order for you to get to your appointment. The Plan denied your request. The Plan says the requested trip exceeds the maximum distance of 50 miles. Additional mileage for routine trips is not covered by your routine transportation benefit. Therefore, this request is denied.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to 24 one-way ground transportation trips per calendar year. Trips must not exceed 50 miles of driving distance. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. The requested location is greater than 50 miles from your residence, and the Plan does not cover routine transportation trips greater than 50 miles. Therefore, we decided that the Plan does not have to provide routine transportation trips with additional mileage allowance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 1, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 for the services provided by an out-of-network provider on March 1,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic visit provided on January 25, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient clinic visit. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 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 outpatient clinic visit provided on January 25,
2021 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis eye emulsion.
You asked the Plan to pre-approve Restasis eye emulsion. You say that you want to treat the enrollee with this drug. The Plan denied your request. The Plan says this drug is not covered by the enrollee's Medicare Part B drug 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 Restasis eye emulsion.
Benefits for Restasis eye emulsion 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4342) for all
four quadrants.
You asked the Plan to pre-approve periodontal scaling and root planing. You say that you are dissatisfied with
your dental coverage and thought more services were covered. The Plan denied your request. The Plan says this
service is not covered by your dental 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. Therefore, we decided that the Plan does not have to pre-approve
periodontal scaling and root planing (D4342) for all four quadrants.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiological services provided by a participating provider on February 3, 2021.
You asked the Plan to waive the copayment for radiological services. You say that this was related to Covid-19. You say that you should not have to pay for this. 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 $100 copayment for outpatient diagnostic tests/diagnostic tests. You have been asked to pay $34.82 which is less than your copayment amount of $100 for radiological services. Radiological services fall within the outpatient diagnostic tests/diagnostic tests 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 radiological services provided by a participating provider on February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 29, 2021.
You asked the Plan to pay for the 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 for the services provided by an out-of-network provider on January 29, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a catheter placement in coronary artery (93458).
You asked the Plan to pre-approve a catheter placement in coronary artery. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for coverage have not been met because the requested procedure is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 a catheter placement in coronary artery. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that, although the enrollee does not have symptoms, the enrollee has electrocardiogram (EKG) evidence of ischemia a relatively low cardiac workload. In addition, the enrollee's left ventricular ejection fraction (LVEF) is not normal by echocardiography. Given these findings, with a history of established coronary artery disease (CAD) and prior coronary artery bypass grafting (CABG) 6 years ago, assessment of the enrollee's coronary anatomy and coronary bypass grafts by cardiac catheterization would meet the American Heart Association/American College of Cardiology appropriate use guideline indication (post CABG, intermediate risk stress test, mildly depressed LVEF). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a catheter placement in coronary artery have been met. Therefore, we decided that the Plan has to pre-approve a catheter placement in coronary artery (93458).
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities provided on January 13, 2021.
You asked the Plan to pay for therapeutic activities. The Plan denied your request. The Plan says the documents submitted for this appeal consist of progress notes for various dates other than the billed date of service.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents
to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities provided on January 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0120, D1110, D0274) received March 16, 2021 from the out-of-network provider.
You asked the Plan to pay for the dental services (D0120, D1110, D0274). You say that you were not told by the provider's office that they were out-of-network when you received the services. The Plan denied your request. The Plan says when you receive services from an out-of-network provider you are responsible for 100% of the cost.
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 when they are received from an out-of-network provider. Therefore, we
decided that the Plan does not have to pay for the dental services (D0120, D1110, D0274) received March 16, 2021 from the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. You say that The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that you were told you could continue to see this provider. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on February 15, 2021 by an OON provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the treatment the enrollee received was medically necessary. The Plan denied your request. The Plan says the services were rendered by a non-participating provider. The Plan also says that 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 the domiciliary or rest home visit provided on
February 15, 2021 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating provider on December 16, 2020.
You asked the Plan to waive the copayment for an x-ray. 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 $14 copayment for outpatient diagnostic tests/in-network/x-rays. You have been asked to pay a $14 copayment for an x-ray. The correct copayment has been applied to the services that were provided. An x-ray falls within the outpatient diagnostic tests/in-network/x-rays 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 x-ray provided by a participating provider
on December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D2751) for teeth # 8 and 10, and a pontic (D6242) for tooth # 9.
You asked the Plan to pre-approve the dental services. You say that you have trouble with gluing and removing of temporary dentures. The Plan says that this is having an effect on your gums. You say that a bridge will help avoid gum trouble and help with your missing crown. You also say that you need this procedure to be approved. The Plan denied your request. The Plan says retainer crowns are not listed as covered service. The Plan says that pontic is not listed as a covered service either. The Plan also says that if a service is not listed in the benefit chart, then it is not covered.
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-approve retainer crowns (D2751) for teeth # 8 and 10, and a pontic (D6242) for tooth # 9.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the biopsy provided from February 22, 2021, to February 25, 2021.
You asked the Plan to waive the copayment for the biopsy. You say that you should be reimbursed this copayment because you needed to have the biopsy repeated and pay another copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $250
copayment per day, per Medicare-covered stay for days 1-5 after you pay your $500 deductible for in-network
inpatient hospital care.
You have been asked to pay a $250 copayment for the biopsy. The biopsy falls within the "Inpatient hospital
care" benefit category. The record shows the biopsy procedure was scheduled while you were an inpatient and
you are responsible for the hospital stay. 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 biopsy
provided from February 22, 2021, to February 25, 2021.
Your complaint about the error during the biopsy procedure is not a valid appeal for medical coverage. This
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 14, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 for the services provided by an out-of-network provider on October
14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on December 21, 2020.
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.
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 physical therapy services provided on December 21, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on December 1, 2020.
You asked the Plan to pay for the evaluation and management service. You say that the claim was paid and then recouped. You also say that you want repayment or an explanation for the recoupment. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice
is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on
December 1, 2020.