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

We decided that the Plan does not have to pay for outpatient surgery provided to the enrollee on November 4, 2019.
You asked the Plan to pay for the services. You say that payment should be made. The Plan denied your request. The Plan says prior authorization for outpatient surgery is required.
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 rendering 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 outpatient surgery provided to the enrollee on November 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 8, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed service cannot be verified.
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 documentation of the ordering physician's intent that the tests 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 December 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the personal emergency response system
You asked the Plan to pre-approve the personal emergency response system. You say that you need the
emergency response system to be approved. You are high risk. You live by yourself and has a history of falling
and breathing problems. This is a medical need for your medical conditions and safety. The Plan denied your
request. The Plan says this item is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve the personal emergency response system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity.
You asked the Plan to pre-approve Trulicity. You say that the enrollee is not a candidate for Metformin given Stage IV CKD. The Plan denied your request. The Plan says Trulicity is considered self-administered and not covered under the medical benefit.
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 pre-approve Trulicity.
Benefits for Trulicity 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.
You asked the Plan to pre-approve the requested services. You say that the enrollee has a history of back pain.
The Plan denied your request. The Plan says only one medial branch block was completed.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions 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 the enrollee has low back and hip pain. She has a history of trochanteric bursitis of both
hips and chronic pain syndrome, and is status post knee replacement and laminectomy. An EMG revealed right
L4 and bilateral L5 radiculopathies with a possible S1 radiculopathy. On exam, she had spasm and tenderness
in the paraspinal muscles, gluteal muscles, and facet joints. Facet load test was positive bilaterally. She has
been taking Tylenol and Tramadol for pain relief. A medial branch block performed in February 2020 relieved
her pain. She had bilateral trochanteric bursa injections in March 2020 with 100% pain relief. In this case, only
one MBB was completed in the past. The review has determined that the enrollee does not meet the coverage
criteria for the requested service.
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 radiofrequency ablation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for inpatient hospital care provided to the
enrollee from January 14, 2020 through January 15, 2020 by an in-network provider.
You asked the Plan to waive the deductible for inpatient hospital care. You say that there should be no cost for
the colonoscopy and endoscopy. The Plan denied your request. The Plan says the claim was processed
accordingly with the member's 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that the enrollee received inpatient hospital care from January 14, 2020 through
January 15, 2020. At the time of services rendered the enrollee had not met their $1,000 deductible; therefore,
the enrollee has been asked to pay $403.83 for the services to apply to their deductible. This means that the
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan
does not have to waive the deductible for inpatient hospital care provided to the enrollee from January 14, 2020
through January 15, 2020 by an in-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nine core buildups, including any pins when required
(D2950 x9).
You asked the Plan to pre-approve the core buildups. The Plan denied your request. The Plan says this service
is 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, 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 nine
core buildups, including any pins when required (D2950 x9).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99285) and electrocardiogram (93010) provided on January 11, 2020.
You asked the Plan to pay for the emergency department visit and electrocardiogram. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim did not include an appropriate primary, first-listed or principal diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency department visit and electrocardiogram have not been met. Specifically, the record indicates that this diagnosis involves an adverse effect of a drug. The diagnosis code for the nature of the adverse effect is not listed first. Therefore, we decided that the Plan does not have to pay for an emergency department visit (99285) and electrocardiogram (93010) provided on January 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a back-up battery for a continuous positive airway
pressure (CPAP) device.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we
decided that the Plan does not have to pre-approve a back-up battery for a continuous positive airway pressure
(CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthopedic bed and mattress.
You asked the Plan to pre-approve an orthopedic mattress. You say that you do not want a hospital bed. You have scoliosis and will be having multiple surgeries. You were advised that you need an orthopedic bed with a pillow top mattress and a bed remote. The Plan denied your request. The Plan says an orthopedic bed is not covered. The plan has instead approved the enrollee for a semi-electric hospital bed and mattress, which will allow the enrollee to position her body to alleviate pain.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at this file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an orthopedic bed and mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve an orthopedic bed and mattress.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown (D2740) and core buildup (D2950) for tooth
#19.
You asked the Plan to pre-approve the crown (D2740) and core buildup (D2950) for tooth #19. You say that
you have been having constant discomfort and need to relieve the pain. The Plan denied your request. The Plan
says there is no clear need for a replacement.
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 the crown
(D2740) and core buildup (D2950) for tooth #19 when the services are medically necessary and reasonable.
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 crown (D2740) and core buildup
(D2950) for tooth #19. Our reviewer says that the criteria for coverage has not been met. Our physician
reviewer found there are no caries or defects on tooth #19, therefore a replacement crown is not necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the crown (D2740) and core buildup (D2950) for tooth #19 have not been met.
Therefore, we decided that the Plan does not have to pre-approve the crown (D2740) and core buildup (D2950)
for tooth #19.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that the provider is known for complex spine surgery. The Plan denied your request. The Plan says you do not have out-of-network benefits, and services are available in-network.
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 orthopedic services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve orthopedic services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on June 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says 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 physician services provided on June 11, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on April 16, 2019 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 April 16, 2019 by an
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ophthalmic diagnostic imaging provided on December 2, 2019 and February 24, 2020.
You asked the Plan to waive the copayments for ophthalmic diagnostic imaging. You say that you should not be charged for imaging. 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 each diagnostic procedure or test. You received ophthalmic diagnostic imaging on December 2, 2019. Therefore, you are responsible to pay the $40.96, which is less than the $65 copayment. You received ophthalmic diagnostic imaging on February 24, 2020. Therefore, you are responsible to pay the $40.96, which is less than the $65 copayment. The total amount you owe is: $81.92. You have been asked to pay the total copayment amount of $81.92 for ophthalmic diagnostic imaging. Ophthalmic diagnostic imaging 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 copayments for ophthalmic diagnostic imaging provided on December 2, 2019 and February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the hearing aids.
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says the benefit allows for coverage of only a select brand of
hearing aids indicated in the Plan contract.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Specifically, the Plan benefit offers coverage only for a select
brand of hearing aids indicated in the Plan contract. Your request is not within this brand of covered hearing
aids. Therefore, we decided that the Plan does not have to pre-approve the hearing aids.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EKG provided on February 3, 2020.
You asked the Plan to waive the copayment for the EKG. You say that you are appealing this claim. The Plan
denied your request. The Plan says you have been charged the correct cost sharing 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 Medicare-covered non-radiological diagnostic services. For this date of service, you have been
asked to pay the allowed amount of the claim because this amount is less than the $20 copayment for the EKG.
You have been asked to pay a $18.43 copayment for the EKG. The EKG falls within the "Outpatient
Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows you were charged
for an EKG during your annual wellness exam.
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 EKG provided on February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on November 5, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory
requisition form. The Plan denied your request. The Plan says the denial of payment for these services is
correct, because the documentation submitted does not support a valid order for this testing.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician
order or clear intent to order the specific lab services billed on this claim. Based on this information, we
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan
does not have to pay for drug testing provided on November 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (CPT 82725) provided to the enrollee on August
27, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Current Procedural Terminology (CPT) code 82725 (1 Unit) remains 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 82725 is "Fatty acids, nonesterified."
We find that CPT code 82725 is not supported in the medical record. Specifically, the place of service on the
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's
office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have
not been met. Therefore, we decided that the Plan does not have to pay for lab services (CPT 82725) provided
to the enrollee on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that this is the only specialist near the enrollee. The Plan denied your request. The Plan says the requested provider is not in your network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve oncology services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from January 18, 2020 to January 24, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not aware there was such a high copayment for the inpatient stay. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $370 copayment per day for days 1-5, then a $0 copayment after day 5 for each Medicare-covered inpatient stay. You have been asked to pay a $370 copayment for each day for days 1 to 5 of the inpatient hospital stay. ($370 x 5 = $1,850). The inpatient hospital stay falls within the "Inpatient hospital care" 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 the inpatient hospital stay provided from January 18, 2020 to January 24, 2020.