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

We decided that the Plan has to waive the copayments forthe immunotherapy injections provided from July 26, 2019 to October 16, 2019.You asked the Plan to waive the copayments forthe immunotherapy injections. You say that the Plan did not cover the immunotherapy injections. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There were no Explanations of Benefit or claim forms submitted with the code at issue to verify the billed services. Therefore, the plan has not shown that the copayment amounts you are being asked to pay are correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the copayments forthe immunotherapy injections provided from July 26, 2019 to October 16, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forlimited oral exam (D0140) provided March 2, 2020.You asked the Plan to pay forthe dental services. You say that your bridge came loose on 2 of the 3 implants. Your regular dentist had retired and after several referrals to different providers you were able to get the bridge permanently cemented back on.The Plan denied your request. The Plan says this service exceeds the benefit frequency limitation.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. This service is allowed once per year. The records show that this service was provided January 30, 2020.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 at this time.Therefore, we decided that the Plan does not have to pay forlimited oral exam (D0140) provided March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair and a raised toilet seat.
You asked the Plan to pre-approve a shower chair and a raised toilet seat. You say that you need the requested items because you are going to have hip replacement surgery. You say that the items are medically necessary to help you with your daily activities. The Plan denied your request. The Plan says these items are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs and raised toilet seats are not covered because they are not primarily medical in nature. While a shower chair and a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a shower chair and a raised toilet seat.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from January 16, 2020 to January 18, 2020.
You asked the Plan to pay for the self-administered drugs. You say that these medications were given to you during a hospital stay, and they made you take them. The Plan denied your request. The Plan says self-administered drugs are not covered under the Part B of this Medicare Advantage Plan.
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 pay for the self-administered drugs provided from January 16, 2020 to January 18, 2020.
Benefits for the self-administered drugs 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Superion, interspinous and/or interlaminar device
(22869, 22868).
You asked the Plan to pre-approve Superion, interspinous and/or interlaminar device. You say that the services
are necessary. The Plan denied your request. The Plan says medical necessity has not been established.
Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are 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 Superion, interspinous and/or
interlaminar device. Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found the spacer remains experimental. More
research is needed to show safety and efficacy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Superion, interspinous and/or interlaminar device have not been met. Therefore,
we decided that the Plan does not have to pre-approve Superion, interspinous and/or interlaminar device
(22869, 22868).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic radiology provided from February 3, 2020 to February 19, 2020.
You asked the Plan to pay for the therapeutic radiology. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 and the ordering provider in this case are not network providers 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 therapeutic radiology provided from February 3, 2020 to February 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a digital breast tomosynthesis (77062) provided December 4,
2019.
You asked the Plan to pay for the digital breast tomosynthesis. You say that the services were medically
necessary. The Plan denied your request. The Plan says this code is not valid for Medicare payment.
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 77062 is not supported in the medical record. Specifically, code 77062 is not valid for
Medicare purposes per the 2019 Year National Physician Fee Schedule. Based on this information, we decided
that Medicare rules for coverage of the digital breast tomosynthesis have not been met. Therefore, we decided
that the Plan does not have to pay for a digital breast tomosynthesis (77062) provided December 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Magnetic Resonance Imaging of the Spine (72141)
provided March 9, 2020.
You asked the Plan to pay for the MRI. You say that the services are medically necessary. The Plan denied
your request. The Plan says there were network providers available. The services were not emergent or
preauthorized.
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 service 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 Magnetic Resonance Imaging of the Spine (72141) provided March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for panoramic dental x-rays (D0330) provided February 5, 2020.
You asked the Plan to pay for the panoramic x-rays. You say that the x-rays should be covered. The Plan
denied your request. The Plan says only bite-wing x-rays are covered. Panoramic x-rays are 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 items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for
panoramic dental x-rays (D0330) provided February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the transport chairs purchased on January 21, 2020 and January 29, 2020, the ramp, or the grab bars purchased on January 30, 2020.
You asked the Plan to reimburse you for the transport chairs, ramp and grab bars. You say that the wheelchairs need to be narrow to pass through your home and you were required to have a ramp in order to be released from the skilled nursing facility. The Plan denied your request. The Plan says these items are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rule say no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.
Durable medical equipment purchased privately through the internet, or by private purchase are not eligible for coverage by your Medicare governed health plan. Medicare does not cover home modifications. Also, the ramp is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. The grab bars are not medical in nature. Therefore, we decided that the Plan does not have to reimburse you for the transport chairs purchased on January 21, 2020 and January 29, 2020, the ramp, or the grab bars purchased on January 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 15 additional routine transportation trips.
You asked the Plan to pre-approve the 15 additional routine transportation trips. You say that transportation is needed to attend medical appointments. The Plan denied your request. The Plan says the number of trips being requested exceeds the benefit allowance for transportation.
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 a maximum of 60 one-way routine transportation trips per year. We looked at your request, the records in the case file, and the rules. The records show that, at the time of your request, you had received coverage for 59 one-way routine transportation trips in the 2020 calendar year. Based on this information, we decided that the number of trips being requested would exhaust the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 15 additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a medical eye exam (92014) provided November 27, 2019.
You asked the Plan to waive the copayment for the medical eye exam. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost sharing was 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 $45 copayment for Eye Specialist Visits. You have been asked to pay a $45 copayment for the medical eye exam. The medical eye exam falls within the Eye Specialist 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 for a medical eye exam (92014) provided November 27, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy services.
You asked the Plan to pre-approve massage therapy. You say that the enrollee has received significant benefit
from massage therapy, and you deem regular massage therapy to be medically necessary. The Plan denied your
request. The Plan says the denial of authorization for this service is correct, because this massage therapy is not
a covered benefit.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore,
we decided that the Plan does not have to pre-approve massage therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on March 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer 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 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 an office visit provided on March 20, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture - flexible base (CPT D5225).
You asked the Plan to pre-approve the maxillary partial denture. You say that The Plan denied your request.
The Plan says the benefit for dentures has been exhausted.
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, coverage for dentures is limited to one
every 60 months. The records show that the Plan paid for a maxillary partial denture - resin base billed with
CPT code D5211 on April 4, 2019. This means that the benefit for denture services is current exhausted and
that the requested service would exceed the benefit allowance. Therefore, we decided that the Plan does not
have to pre-approve a maxillary partial denture - flexible base (CPT D5225).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on December 24,
2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for physician's services that you provided on December 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for your inpatient treatment program provided
October 22, 2019 to October 30, 2019.
You asked the Plan to reimburse you for your inpatient treatment program. You say that the services are
covered so the Plan should reimburse you for the inpatient treatment program. The Plan denied your request.
The Plan says they requested an itemized bill from the provider but did not receive one.
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 there is no itemized bill provided to process the claim from. Based on this information, we
decided that Medicare rules for coverage of your inpatient treatment program have not been met. Therefore, we
decided that the Plan does not have to reimburse you for your inpatient treatment program provided October
22, 2019 to October 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass lenses and frames (V2020, V2781, V2750) provided February 24, 2020.
You asked the Plan to pay for the eye glasses. You say that the glasses should be covered as they were the last time. The Plan denied your request. The Plan says the glasses were obtained from a non-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.
We looked at the file and the Plan's rules. The eyeglasses were purchased out-of-network which makes them ineligible for the $150 allowance offered by the plan. Based on this information, we decided that the Plan's rules for coverage of the eye glasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass lenses and frames (V2020, V2781, V2750) provided February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 31, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says all nonemergent
services received with a non-Plan provider require approval by the Plan prior to the services being
rendered.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services,
plans are not required to make payments for any services received by enrollees that are not provided directly by
the Plan or through arrangements made by the Plan.
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not
have to pay for physician's services provided on January 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740) provided February 14, 2020.
You asked the Plan to pay for the crown. You say that the crown was medically necessary. The Plan denied your request. The Plan says crowns are 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 for a crown (D2740) provided February 14, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 19, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says
you are not a contracted provider and written, approved prior authorization for this services is absent.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services,
plans are not required to make payments for any services received by enrollees that are not provided directly by
the Plan or through arrangements made by the Plan.
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not
have to pay for subsequent nursing facility care provided on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 6,
2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says
all non-emergent services received with a non-Plan provider require approval by the Plan prior to the services
being rendered.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services,
plans are not required to make payments for any services received by enrollees that are not provided directly by
the Plan or through arrangements made by the Plan.
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not
have to pay for subsequent nursing facility care provided on February 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an esophagogastroduodenoscopy provided on January 24,
2020.
You asked the Plan to pay for the esophagogastroduodenoscopy. The Plan denied your request. The Plan says
that the Plan requires utilization of network providers when possible and available, and requires authorization
for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for an esophagogastroduodenoscopy provided on January 24, 2020.