Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the addition of a tooth to an existing partial denture (D5650),
and the unspecified preventive service (D1999 x 2) provided from April 4, 2021, to April 28, 2021.

You asked the Plan to pay for the addition of a tooth to an existing denture and the unspecified preventive
services. You say that you had 2 claims that were completely denied. You also say that at least some of the
services should be covered. The Plan denied your request. The Plan says addition of a tooth to an existing
partial denture is not listed as a covered service. The Plan also says that unspecified preventive services are not
listed as covered services 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 addition of a tooth to an existing
partial denture and the unspecified preventive services are not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the addition of a tooth to an existing partial
denture (D5650), and the unspecified preventive service (D1999 x 2) provided from April 4, 2021, to April 28,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next test strips.
You asked the Plan to pre-approve Contour Next test strips. You say that these are medically necessary. The Plan denied your request. The Plan says that your provider concluded you can use the preferred product.
Medicare rules say that MA plans may specify brands and manufacturers as preferred. The contract with your Plan says that specific brands of diabetic testing supplies are covered by the health plan. Contour Next test strips are not a preferred brand under the health plan's contract. Therefore, we decided that the Plan does not have to pre-approve Contour Next test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on April 26, 2021.
You asked the Plan to pay for the dental service. You say that you needed to have an infected tooth removed. You also say that you need this done so you can have the surgery to remove your cancer. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan also says that you signed an agreement verifying that you agreed to be responsible for all services rendered on your behalf.
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 limited oral evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out-of-network (OON) provider on October 9, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out-of-network (OON) provider on October 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on January 7, 2021.
You asked the Plan to pay for a limited oral evaluation. You say that the service should be covered. The Plan denied your request. The Plan says the service at issue 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 pay for a limited oral evaluation (D0140) provided on January 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs these services for complex wound care. The Plan denied your request. The Plan says that the enrollee is able to safely receive the care she needs in another setting.
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. The enrollee is receiving appropriate care at her present setting. The enrollee does not require services at the LTACH that are not available at the setting where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says your care remains complex.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 physician reviewer found that you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. 

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-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Synvisc-One (J7325).

You asked the Plan to pre-approve Synvisc-One. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested drug is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Synvisc-One. Our reviewer says that the requested treatment is not medically necessary in this case. Our physician reviewer found that there is no documentation of adequate conservative measures for knee pain to include recent physical therapy. There is no documentation of the response from the prior knee injection. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Synvisc-One (J7325).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 15, 2020.
You asked the Plan to pay for the laboratory services. You say that the coronavirus claims that were submitted have not been paid. You say that the denial should be reevaluated on the recommendation of the CARES Act. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
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 laboratory services provided on December 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for compression stockings purchased out of network for a non-Medicare eligible provided on March 31, 2021.
You asked the Plan to pay for these items. You say that the Plan should pay for these compression stockings. The Plan denied your request. The Plan says these compression stockings were purchased out of network from a provider who is not a Medicare eligible provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program.
These items were purchased out of network, without prior authorization from a provider who is not a Medicare eligible durable medical equipment provider. Therefore, we decided that the Plan does not have to pay for compression stockings purchased out of network for a non-Medicare eligible provided on March 31, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided out of network from October 12, 2020, to December 28, 2020.
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided out of network from October 12, 2020, to December 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology services provided on March 11, 2021.
You asked the Plan to pay for the molecular pathology services. The Plan denied your request. The Plan says the records submitted to the Plan do not support the additional number of seven units billed for code G0452. The provider has not submitted any clinical records to review.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents
to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the molecular pathology services have not been met. Therefore, we decided that the Plan does not have to pay for molecular pathology services provided on March 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

February 3, 2021, through March 18, 2021.
You asked the Plan to waive the copayment for cardiac rehabilitation. You say that if you knew it would be $30 every time you would have went to the gym. You say that you already paid $270 and they are asking for more. The Plan denied your request. The Plan says the copayments applied correctly.
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 $30 copayment per visit for Medicare-covered cardiac rehabilitation and intensive cardiac rehabilitation services from a network provider.
You have been asked to pay a $30 copayment for each cardiac rehabilitation visit. Cardiac rehabilitation falls within the "Cardiac rehabilitation services" 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 cardiac rehabilitation provided from February 3, 2021, through March 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (POC).
You asked the Plan to pre-approve a POC. You say that the enrollee cannot push a cart with tank system when going to appointments, church and social activities. The Plan denied your request. The Plan says the enrollee has not tried a home-fill system with portable oxygen tanks which is the standard item.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. We looked at the file and Medicare rules. The enrollee has not tried the standard item and has not had a pulmonary function test. Based on this information, we decided that Medicare rules for coverage of a POC have not been met. Therefore, we decided that the Plan does not have to pre-approve a POC.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable control system.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says your strength and function are adequate to control the power options using their own switches.

The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered under certain medical indications. 

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 requested services. Our physician reviewer found that you do not need to operate 3 or more powered options through the drive control. Your strength and function in the upper extremities, with the ability to feed yourself, indicates that you can control power options through their own individual switches. The attendant control (E2331) is not medically necessary as the power wheelchair includes a user operated control system. 

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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable control system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam computed tomography capture and interpretation (D0365) provided on March 4, 2021.

You asked the Plan to pay for a cone beam computed tomography capture and interpretation. You say that the service was necessary. The Plan denied your request. The Plan says the service at issue is not a covered service.

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 cone beam computed tomography capture and interpretation (D0365) provided on March 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection provided by a participating provider on February 6, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for outpatient surgery/in-network. You have been asked to pay a $300 copayment for an outpatient surgery. The injection that was received is considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls within the outpatient surgery/in-network 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 injection provided by a participating provider on February 6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had on October 1, 2020, at an ambulatory surgery center.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you should not be charged for this because you are eligible for a free routine colonoscopy. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says this was not done for screening purposes.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery at an ambulatory surgery center.
You have been asked to pay a $250 copayment for the diagnostic colonoscopy. Records show that this colonoscopy was not ordered as a screening procedure. Rather, it was performed as part of a workup for heme-positive stool. Because you had a specific condition and symptom for which this colonoscopy was ordered, it is considered a diagnostic, not screening, procedure. Diagnostic colonoscopies are considered surgical services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had on October 1, 2020, at an ambulatory surgery center.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair.
You asked the Plan to pre-approve the requested wheelchair. The Plan denied your request. The Plan says the enrollee does not meet the coverage criteria.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair is only covered under certain medical indications.
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 requested wheelchair. Our physician reviewer found that the enrollee's medical history includes osteoarthritis and ambulation problems. Comorbidities include arthritis, diabetes, hypertension, and a fractured right hip. The enrollee can walk short distances with a walker. However, he has an extensive history of falls, and needs assistance with transfers. The documentation does not reveal that the enrollee has a neurological condition; a myopathy; or a congenital skeletal deformity. Therefore, the coverage criteria for a Group 3 power wheelchair and accessories have not been met.
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 requested wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 5, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also 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 physician's services provided on December 5, 2020.