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

We decided that the Plan does not have to waive the copayment for an office visit provided on November 4, 2019.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with 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 $20 copayment for primary care provider visits. The medical records show that you received services beyond an annual wellness visit on November 4, 2019. Therefore, you are responsible to pay the $20 copayment. You have been asked to pay a $20 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 for an office visit provided on November 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on December 13, 2019.You asked the Plan to reimburse you for the eyeglasses. You say that there are no optical hardware providers where you live.The Plan denied your request. The Plan says there are multiple in-network providers in your area where youcould have purchased these eyeglasses.Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when purchased from a Plan optical facility.We looked at thefile and the Plan's rules. The eyewear provider at issue in this appeal is not a Plan optical facility. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for the eyeglasses provided on December 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 4, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on November 4, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from November 26, 2019 to November 29, 2019.You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this claim has been submitted without the required FIPS code.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim does not include the required FIPS code. Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from November 26, 2019 to November 29, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extraction of teeth #8, 9, 10, 23, 24, 25, and 26 (D7140), surgical removal of erupted tooth for teeth #11, 22, 27, and 29 (D7210), surgical removal of residual tooth roots for teeth #20, 21, 28, and 30 (D7250), evaluation for moderate sedation, deep sedation or general anesthesia (D9219), deep sedation/general anesthesia - first 15 minutes (D9222), and deep sedation/general anesthesia - each subsequent 15 minute increment (D9223).
You asked the Plan to pre-approve extraction of teeth #8, 9, 10, 23, 24, 25, and 26, surgical removal of erupted tooth for teeth #11, 22, 27, and 29, surgical removal of residual tooth roots for teeth #20, 21, 28, and 30, evaluation for moderate sedation, deep sedation or general anesthesia, deep sedation/general anesthesia - first 15 minutes, and deep sedation/general anesthesia - each subsequent 15 minute increment. You say that you need the requested services in order to move forward with dentures. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria has not been met.
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 two non-surgical or surgical extractions per calendar year and necessary anesthesia with covered services. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of extraction of teeth #8, 9, 10, 23, 24, 25, and 26, surgical removal of erupted tooth for teeth #11, 22, 27, and 29, surgical removal of residual tooth roots for teeth #20, 21, 28, and 30, evaluation for moderate sedation, deep sedation or general anesthesia, deep sedation/general anesthesia - first 15 minutes, and deep
sedation/general anesthesia - each subsequent 15 minute increment have not been met. Therefore, we decided that the Plan does not have to pre-approve extraction of teeth #8, 9, 10, 23, 24, 25, and 26 (D7140), surgical removal of erupted tooth for teeth #11, 22, 27, and 29 (D7210), surgical removal of residual tooth roots for teeth #20, 21, 28, and 30 (D7250), evaluation for moderate sedation, deep sedation or general anesthesia (D9219), deep sedation/general anesthesia - first 15 minutes (D9222), and deep sedation/general anesthesia - each subsequent 15 minute increment (D9223).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services rendered on September 26, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 80307 and G0483 are not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 80307 is presumptive drug testing, any number of classes. The definition of code G0483 is definitive drug testing, 22 or more classes.We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, there are no lab results included in the submitted documentation to verify these codes. 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 drug testing services rendered on September26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two core buildups, including any pins when required, (D2950).You asked the Plan to pre-approve the core buildups. You say that the enrollee is not able to floss which is causing periodontal disease. You also say that you recommend replacing the crowns.The Plan denied your request. The Plan says this service 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 items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve two core buildups, including any pins when required, (D2950).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 26, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that when the enrollee switched from Original
Medicare to this plan you were expecting to get the same level of coverage. The Plan denied your request. The
Plan says the denial of payment for these services is correct, because this provider is out-of-network with the
Plan and the ordering provider is also out-of-network with 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 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 medical services provided on December 26,
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
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 November 25, 2019.You asked the Plan to pay forthe 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 forthe medical services provided to the enrollee by an out-of-network provider on November 25, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health services.You asked the Plan to pre-approvethe home health services. You say that you would like reconsideration because the home health services are medically necessary.The Plan denied your request. The Plan says the clinical information does not support the medical necessity of these visits.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 home health services. Our reviewer says that records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for you beyond what was approved by the Plan. Our physician reviewer found there are no complex wounds, new enteral feedings or other skilled nursing needs. Your current needs do not require the skills of a professional nurse for ongoing treatment and medical management of her condition therefore this request is not 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 the home health services have not been met.Therefore, we decided that the Plan does not have to pre-approvehome health services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveposaconazole tablets.You asked the Planto pre-approvethe posaconazole tablets. You say that it is imperative we start this medication as soon as possible to ensure his wellbeing and resolve this life-threatening condition.The Plandenied your request. The Plansaysthis oral drug is not covered by Medicare Part B. Part D coverage must be requested.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 Plandoes not haveto pre-approveposaconazole tablets.Benefits for the posaconazole tabletsmay be available under Medicare Part D.Contactthe 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 reimburse you for the complete upper denture (D5110) and the complete lower denture (D5120) provided on September 30, 2019.You asked the Plan to reimburse you for the dental items. You say that you needed new dentures. You say that the dentures you had were 30 years old. You say they were missing teeth and had a cracked plate. You also say that you need dentures in order to eat.The Plan denied your request. The Plan says dentures are not a covered service.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to reimburse you for the complete upper denture (D5110) and the complete lower denture (D5120) provided on September 30, 2019.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for home health services provided on October 1, 2019 through October 28, 2019.You asked the Plan to pay for the home health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that this claim was submitted without the required treatment authorization code.The Plan must follow Medicare rules. Medicare rules say that any claim with incomplete, missing, or invalid information for all of these elements may be returned as unprocessable.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have been met. Specifically, the record indicates that a corrected claim has been submitted with the required treatment authorization code.Therefore, we decided that the Plan has to pay for home health services provided on October 1, 2019 through October 28, 2019.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture and a mandibular partial denture.
You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that you originally had another dentist provide you with dentures, but you never got them. You also say that you want to get dentures through a new provider. The Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan also says that you had this service less than 60 months ago.
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, complete/partial dentures are limited to once per arch per 60 months. The record shows that you received a complete maxillary denture and a mandibular partial denture on January 12, 2018 and your dentures benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture and a mandibular partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefollow-up care with the doctor at provider.You asked the Plan to pre-approvefollow-up care with Dr. at provider. You say that you have had bad experiences at other provider.The Plan denied your request. The Plan says other provider is qualified to provide the follow-up care being requested.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 follow-up care with Dr. at provider. Our reviewer says that thecriteria for coverage of out-of-network care have not been met. Our physician reviewer found the enrollee is a 45 year old female with a left ovarian granulosa cell tumor and urachal mass who underwent surgical exploration and oophorectomy on May 23, 2019. The possible bladder mass was felt to be related to the ovarian tumor. A follow-up MRI revealed persistent urachal mass and a biopsy with interventional radiology was recommended. other provider is qualified to provide the follow-up care and interventional radiology referral being requested. It is not medically necessary for the enrollee to see the requested out-of-network provider.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of follow-up care with Dr. at provider have not been met.Therefore, we decided that the Plan does not have to pre-approvefollow-up care with Dr. at provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora CT scan provided on November 15, 2019.You asked the Plan to waive the copayment fora CT scan. You say that you disagree with the denial.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 $65 copayment for CT scans. You have been asked to pay a $65 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora CT scan provided on November 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome delivered meals (S5170).You asked the Plan to pre-approvehome delivered meals. You say that it is difficult for you to go out and do your grocery shopping due to your age and health.The Plan denied your request. The Plan says based on the documentation provided, 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home delivered meals have not been met. Specifically, you were not discharged from the hospital or SNF with a stay greater than 2 days.Therefore, we decided that the Plan does not have to pre-approvehome delivered meals (S5170)
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approveSNF services. You say that the enrollee will benefit from short-term rehabilitation.The Plan denied your request. The Plan says that there is no need for daily skilled therapy services to be provided by a skilled therapist on a dailybasis and there are no daily skilled nursing needs.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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found thatthe enrollee's condition does not meet Medicare criteria for SNF services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.You asked the Plan to pre-approve the physician's services. You say that you first saw this physician on June 26, 2015 and he performed several tests for memory loss due to radiation from a brain tumor you had in 1988. You say that you would like to continue to follow-up with this physician as you have established a patient/doctor relationship and he has records and insight into your particular case. The Plan denied your request. The Plan says you must receive care from a network provider.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. We found no exception that would require the Plan to pre-approve the physician's services.Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.