Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis LT,RT (L1833x2) and suspension sleeve LT,RT (L2397x2) provided October 17, 2019.
You asked the Plan to pay for the orthoses. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the services are not supported in the medical records received.
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 pay for the orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is no objective documentation of joint laxity. The documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case.
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 orthoses have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis LT,RT (L1833x2) and suspension sleeve LT,RT (L2397x2) provided October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran office visit provided by a primary care physician on December 16, 2019.You asked the Plan to waive the copayment foran office visit. You say that you went for your annual exam.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 $20 copayment for physician/practitioner services/primary care doctor. You have been asked to pay a $20 copayment for an office visit. When additional services are provided, during an annual wellness exam, additional copayments are applied; therefore, the correct copayment has been applied. An office visit falls within the physician/practitioner services/primary care doctor benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran office visit provided by a primary care physician on December 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Part B injection, the laboratory work, and the blood transfusion provided on January 2, 2020.You asked the Plan to waive the cost share for the Part B injection, the laboratory work, and the blood transfusion. You say that your father should not be responsible for payment.The Plan denied your request. The Plan says the deductible amount for the Part B injection and the laboratory work copayment were removed and the claim was reprocessed with the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible that applies towards blood transfusions, 20% coinsurance for Medicare Part B prescription drugs, a $10 copayment diagnostic lab services and diagnostic procedures and tests and a $125 copayment after the deductible is met for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. The blood transfusion you asked the Plan to waive the cost share for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards blood transfusion.The allowed amount for the blood transfusion is $376.86. Therefore, $376.86 was applied towards the deductible.You have also been asked to pay$229.20 which is 20% of the allowed amount for the Part B injection. The allowed amount is $1,146. ($1,146 x 20% = $229.20). You have also been asked to pay $10 copayment for the laboratory work. The Part B injection falls within the "Medicare Part B prescription drugs" benefit category. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category.The total amount you have been asked to pay is $616.06. ($376.86 + $229.20 + $10 = $616.06).This cost sharing is a contractual obligation that had not been met at the time the Part B injection, the laboratory work, and the blood transfusion were received on January 2, 2020.Therefore, we decided that the Plan does not have to waive the cost share for the Part B injection, the laboratory work, or the blood transfusion provided on January 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe imaging and laboratory services rendered from September 10, 2019 to September 12, 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 the required clinical trial number is missing.The Plan must follow Medicare rules. Medicare rules say that it is mandatory to report a clinical trial number on claims for items/services provided in clinical trials/studies/registries, or under CED.We looked at the file and Medicare rules. The required clinical trial number was not reported on the claims for these services. 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 imaging and laboratory services rendered from September 10, 2019 to September 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for drug test. You say that you cannot turn away specimens as the results are crucial to the enrollee's care with the ordering physician. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the ordering physician 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 November 20, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forspecialist services provided on October 2, 2019 by an out of network (OON) provider.You asked the Plan to pay forspecialist 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. Wefound no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forspecialist services provided on October 2, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power scooter.You asked the Plan to pre-approvea power scooter. You say that you need a fold-able scooter and able to get around.The Plan denied your request. The Plan says that your current equipment meets your needs.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal 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.Therefore, we decided that the Plan does not have to pre-approvea power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forchiropractic services provided on November 4, 2019 by an out of network (OON) provider.You asked the Plan to pay forchiropractic services. You say that you were told that you did not need prior authorization.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 forchiropractic services provided on November4, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an initial consultation (99203) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an initial consultation. You say that it is in your best interest to continue your care. The Plan denied your request. The Plan says there are in-network providers that are able to provide this care. Therefore, coverage criteria has not been met.
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 an initial consultation (99203) to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on October 15, 2019.You asked the Plan to waive the copayment for arthrocentesis. 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 $275 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $275 copayment for arthrocentesis. Arthrocentesis falls within the outpatient surgery, includingservices provided at hospital outpatient facilities and ambulatory surgical centers 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 forarthrocentesis provided on October 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (D3330) and the treatment of root canal obstruction (D3331).You asked the Plan to pre-approve the dental services. You say that you were not advised that your plan changed. You say that you did not receive an Annual Notice of Change (ANOC). You also say that you feel you should have been contacted regarding this change.The Plan denied your request. The Plan says root canal is not listed as a covered service. The Plan says treatment of root canal obstruction is not listed as a covered service either.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 root canal and treatment of root canal obstruction are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve a root canal (D3330) and the treatment of root canal obstruction (D3331)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation provided on December 16, 2019.You asked the Plan to pay forthe problem focused limited oral evaluation. You say that you are on a limited income. You also say that you were having problems with your teeth being very sensitive and you needed treatment to relieve your pain.The Plan denied your request. The Plan says this service exceeds the maximum allowed per period.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, exams are limited to two procedures per plan year. The records show that you received a problem focused limited oral evaluation on December 2, 2019 and December 5, 2019 and your exams benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe problem focused limited oral evaluation provided on December 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 23, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, 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. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies.You say that please approve the supplies due to being incontinent and you are unable to make it to your bedside toilet due to spinal surgery from C2 to L4. A diaper leaves you with a severe rash from the plastic.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 incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies 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-approveincontinence supplies.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forservices provided on September 2, 2018.You asked the Plan to pay forthe ambulance services. You say that the claim was timely.The Plan denied your request. The Plan says the claim was untimely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the ambulance services was notfiled until November 20, 2019.This means that more than one calendar year from the date of service had passed before aclaim was filed.Therefore, we decided that the Plan does not have to pay forservices provided on September 2, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean epidural steroid injection (ESI) for enrollee.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that an ESI is covered when specific criteria are met.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. He had a spinal cord stimulator placed in the past but is no longer using it. His physical exam shows tenderness over the lumbar area, but there is no limitation of flexion or extension noted. There is no motor or sensory loss. The straight leg raising test is negative. The enrollee does not have an indication for the ESI and the services are not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvean epidural steroid injection (ESI) for enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cataract surgery (66984) provided on October 29, 2019.
You asked the Plan to pay for cataract surgery. You say that you don't believe you had other insurance at this
time. The Plan denied your request. The Plan says this claim must be submitted to your primary insurance.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has instructed
this claim to be submitted to your primary insurance carrier for the date of service. As the secondary insurer,
the Plan cannot be held responsible for cataract surgery until the primary insurer has denied the claim for these
services. Therefore, we decided that the Plan does not have to pay for cataract surgery (66984) provided on
October 29, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional transportation. You say that you have no ride to dialysis. The Plan denied your request. The Plan says your benefit only allows 36 one-way trips for this service.
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 36 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan's maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe occlusal guard (D9944) provided on December 10, 2019 by an out of network provider.You asked the Plan to pay forthe dental item. You say that you needed the occlusal guard to prevent further damage to your teeth from grinding. You say that you have had a lot of bad experiences in the past with other dentists. You also say that you are going to continue to see this dentist.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says dental services that you receive out of network are 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, dental items received out of network are not covered.Therefore, we decided that the Plandoes not have to pay forthe occlusal guard (D9944) provided on December 10, 2019 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea mandibular partial denture.You asked the Plan to pre-approvethe mandibular partial denture. You say that your lower gum is making you uncomfortable. You also say that you cannot eat outside because your tooth keeps falling out.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 mandibular partial denture on June 29, 2017 and your dentures benefit has been exhausted.Therefore, we decided that the Plan does not have to pre-approvea mandibular partial denture