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

We decided that the Plan does not have to pre-approve dental implants.
You asked the Plan to pre-approve dental implants. The Plan denied your request. The Plan says the dental implants are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve dental implants.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 16, 2019.
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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on December 16, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prosthetic lenses.
You asked the Plan to pre-approve prosthetic lenses. You say that the requested prosthetic lenses are medically necessary. The Plan denied your request. The Plan says the requested prosthetic lenses are not covered.
The Plan must follow Medicare rules. The rules say the term "internal body organ" includes the lens of an eye. We looked at the file and Medicare rules. Medicare says prostheses replacing the lens of an eye include post-surgical lenses customarily used during convalescence from eye surgery in which the lens of the eye was removed. Permanent lenses are also covered when required by an individual lacking the organic lens of the eye because of surgical removal or congenital absence. The file shows that the enrollee is with a diagnosis of Mydriasis. The enrollee underwent a stripping endothelial keratoplasty in 2018. She now has a fixed open pupil, with light sensitivity. The enrollee's optometrist has recommended a Cantor prosthetic lens to allow reduced light sensitivity. Medicare does not usually cover contact lenses. Medicare Part C plans may offer extra benefits. The enrollee's plan covers contact lenses for enrollees who are aphakic and do not have an intraocular lens, hydrophilic contact lenses for corneal bandaging, and rigid contact lenses for keratoconus. Contact lenses are otherwise non-covered. Therefore, we decided that the Plan does not have to pre-approve prosthetic lenses.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing provided on February 27, 2020.
You asked the Plan to waive the copayment for lab tests. You say that you do not feel that you should pay a second copayment because the hospital made a mistake. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $10 copayment per day, per provider for in-network covered lab services. These tests were provided on a separate date of service; therefore, a separate copayment applies to this claim. You have been asked to pay $10 copayment for lab tests. Lab tests fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory testing provided on February 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found as LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH at this time. The enrollee can remain at the current acute care hospital until such time as no acute services are required, then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral periapical x-ray, 4 resin-based composites, and 3 applications of desensitizing medicament provided from September 21, 2018 to November 19, 2018.
You asked the Plan to pay for the intraoral periapical x-rays, resin-based composites, and applications of desensitizing medicament. You say that you do not understand why these bills have not been paid when you have dental insurance. The Plan denied your request. The Plan says these services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral periapical x-ray, 4 resin-based composites, and 3 applications of desensitizing medicament provided from September 21, 2018 to November 19, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on February 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the member's primary care physician did not refer these services. The Plan says that 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 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 tests provided on February 13, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.You asked the Plan to pre-approve Orthovisc. You say that you want to be treated with this drug.The Plan denied your request. The Plan says you have not first tried and had a contraindication or intolerance to Synvisc/Synvisc-One, Durolane, and Gelsyn-3.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 Orthovisc. Our reviewer says that the drug is not medically necessary and reasonable. Our physician reviewer found that the health plan's denial should be upheld.A request has been made for Orthovisc, a hyaluronic acid injection, to apparently treat osteoarthritis of the knee. The health plan requires that other forms of hyaluronic acid injections be used. There is no evidence that the enrollee is allergic to or intolerant of these other forms of hyaluronic acid.  There is no evidence that the enrollee has tried and not responded to these other forms of hyaluronic acid injections. There is no documentation as to why these other forms of hyaluronic acid would not be expected to be safe and effective for the enrollee. Therefore, the requested Orthovisc is not shown to be currently medically necessary and reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met.Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical supplies provided on December 18, 2019.
You asked the Plan to pay for the medical supplies. You say that the Plan should pay this claim. The Plan denied your request. The Plan says there are conflicting dates and tracking information.
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 physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid and proof of delivery for the supplies provided in this case. The claim date of service is neither the shipping date or the delivery date. Therefore, we decided that the Plan does not have to pay for the medical supplies provided on December 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on December 7, 2019 to January 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that this should be covered by your out of network benefits. The Plan denied your request. The Plan says that there were network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says 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 chiropractic services provided on December 7, 2019 to January 29, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for dental services.You asked the Plan to pay for dental anesthesia. You say that this can only be done under anesthesia.The Plan denied your request. The Plan says this is not a covered benefit.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 service is not among those covered under this benefit. The plan covers only preventive dental services. The requested dental anesthesia is not covered under your plan.Therefore, we decided that the Plan does not have to pay for anesthesia for dental services
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for CT scans provided on March 19, 2020.
You asked the Plan to waive the copayments for CT scans. You say that you thought that you would only owe one $150 copayment and did not realize you received more than one scan. 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 $150 copayment for each advanced imaging service. The medical records show that you received 3 CT scans on March 19, 2020. Therefore, you are responsible to pay the total copayment amount of $230.78, which is less than the total copayment amount. You have been asked to pay the total copayment amount of $230.78 for CT scans. CT scans fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for CT scans provided on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the subsequent nursing facility care.
You asked the Plan to pre-approve the subsequent nursing facility care. 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the subsequent nursing facility care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have a pneumatic compression device (E0652)and segmental pneumatic appliance (E0667x2).
You asked the Plan a pneumatic compression device and appliance. You say that you ask that the plan reverses the coverage denial so that the enrollee may begin daily treatment as directed by the attending physician. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four week trial of a basic pneumatic compression device of either E0650 or E0651.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have a pneumatic compression device (E0652)and segmental pneumatic appliance (E0667x2).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that on the date of service your glucose levels went down and 911 was called. When the responding paramedics arrived, they were able to get your glucose levels back up. You say that the treatment resolved the problem and there was no need to go to the hospital. You stated that the services were necessary because otherwise it possibly could have cost you your life.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 12, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on December 4, 2019.You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 codes 80307 and G0482 are not supported in the medical record. Specifically, the documentation submitted does not indicate the method of testing utilized to support the presumptive drug test. The method of testing should be documented within the lab results to validate the billed services. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on December 4, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography of the head or brain (70450) and the x-ray exam of the chest (71045) provided on October 3, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that during the hospice election, fee-for-service Medicare covers attending physician services and all care unrelated to the terminal illness until the first day of the month, following the month in which hospice was revoked or discharged.
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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the computed tomography of the head or brain (70450) and the x-ray exam of the chest (71045) provided on October 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that the enrollee needs the power seat elevation feature for transfers at home while alone. The Plan denied your request. The Plan says a power seat elevation feature is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. A power seat elevation feature does not serve a purpose that is primarily medical in nature and therefore is not covered. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.

You asked the Plan to pre-approve a power mobility device. You say that because of a hip injury it is hard for you to move around for your appointments and a scooter would be helpful. The Plan denied your request. The Plan says there is no face-to-face evaluation or physician order.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. There is no physician order or home assessment documentation. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. 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 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 physician services provided by an out of network (OON) provider.