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

We decided that the Plan does not have to pay for radiology services provided to the enrollee on October 15, 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 the primary carrier's Explanation of Benefits was not received.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 not received a primary Explanation of Benefits yet. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay for radiology services provided to the enrollee on October 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc One.
You asked the Plan to pre-approve Synvisc One. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc. Our physician reviewer found the enrollee has knee pain and has a diagnosis of bilateral knee osteoarthritis. The enrollee has failed conservative treatment. The provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 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 Synvisc One.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean interim obturator prosthesis (D5936).You asked the Plan to pre-approvethe interim obturator prosthesis. You say that this service is medically necessary.The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit package.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-approvean interim obturator prosthesis (D5936).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by Manse an out of network (OON) provider.You asked the Plan to pre-approvethe referral. You say that the enrollee has ongoing scrotal swelling, and has seen two urology practices with no resolution of symptoms.The Plan denied your request. The Plan says medically necessary covered services are available from in-network providers.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-approvethe medical services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean emergency response system.You asked the Plan to pre-approvethese services. You say that you are alone most of the time and feel the services would be helpful.The Plandenied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that items that do not contribute meaningfully to the treatment of an illness or injury or the functioning of a malformed body member are not covered.The item at appeal is a medical life alert system. While this item may be of benefit to you, it is not covered by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvean emergency response system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on June 19, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that the doctor should have checked if the lab was in-network.The Plan denied your request. The Plan says there are contract providers available for this service.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 OON services. Therefore, we decided that the Plan does not have to pay forthe lab services provided on June 19, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring system.
You asked the Plan to pre-approve a continuous glucose monitor. You say that it is very painful and burns after finger stick testing. The Plan denied your request. The Plan says you do not meet the listed criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. The record shows you do not test four or more times a day or are insulin treated three or more times every day. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring system.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the computed tomography (CT) guidance rendered to you from November 18, 2019 to December 3, 2019.
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayments were 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 $100 copayment for each Medicare-covered radiologic diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility.
Review of the file shows that you received CT guidance for eight dates of service from November 18, 2019 to December 2, 2019. You have been asked to pay a $100 copayment per date of service for these services, for a total of $800. These services fall within the Medicare-covered radiologic diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility 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.
The file shows that you received CT guidance on December 3, 2019. Your contract with the Plan clearly says that you must pay a $100 copayment for each Medicare-covered radiologic diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility. However, the Medicare allowed amount for these services was $70.50. Given that the allowed amount was less than the $100 copayment, you have been asked to pay $70.50 for these services.
Therefore, we decided that the Plan does not have to waive the copayments for the computed tomography (CT) guidance rendered to you from November 18, 2019 to December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Part B injection provided on January 13, 2020.You asked the Plan to waive the coinsurance forthe Part B injection. You say that you were told you would only have to pay a $15 copayment. You say you would not have gotten the injection if you had known the injection would cost this much. 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay $215.37 which is 20% of the allowed amount for the Part B injection. The allowed amount is $1,076.86. ($1,076.86 x 20% = $215.37). The Part B injection falls within the "Medicare Part B prescription drugs" 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 coinsurance forthe Part B injection provided on January 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide the specialized scooter.
You asked the Plan to provide a Group 1 power operated vehicle. You say that the enrollee needs a scooter. The Plan denied your request. The Plan says a PMD is not medically necessary at this point.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that the enrollee's condition can be improved by a cane or walker. The assessment shows the enrollee has a four-wheeled walker with seat that should be used on a consistent basis for completing ADLs and a 3-wheeled scooter is not considered stable. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to provide a PMD.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve a referral for the enrollee for penile implant surgery.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested procedure can be provided 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 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 Plandoes not haveto pre-approvea referral for the enrollee for penile implant surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on November 5, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on November 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair (K0003).
You asked the Plan to pre-approve the manual wheelchair. You say that you would like reconsideration because the member requires the manual wheelchair to go to medical appointments and community outings. The Plan denied your request. The Plan says backup wheelchairs are not covered by Medicare and Medicare requires mobility devices to be used within the home.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee has a power wheelchair. a power wheelchair serves the same purpose as the manual wheelchair. Additionally, the record indicates that the manual wheelchair is for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair (K0003).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested bilateral lower limb prostheses.You asked the Plan to pre-approve the bilateral lower limb prostheses.The Plan denied your request. The Plan says that the Plan does not cover non-emergency services by a non-contracted provider when a contracted provider can provide the equipment/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 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 itemsat issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approvethe requestedbilateral lower limb prostheses.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lyrica for the enrollee.
You asked the Plan to pre-approve Lyrica. You say that Lyrica is medically necessary for the enrollee. The Plan denied your request. The Plan says self-administered drugs are not covered under Medicare Part B.
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 Lyrica for the enrollee.
Benefits for Lyrica 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 Brilinta.
You asked the Plan to pre-approve Brilinta. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Brilinta is not covered under the enrollee's Medicare Part B 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 Brilinta.
Benefits for Brilinta 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe special pump services rendered on October 23, 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 services are not covered.The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.Therefore, we decided that the Plan does not have to pay forthe special pump services rendered on October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the initial periapical
x-ray (D0220) provided on December 13, 2019.
You asked the Plan to pay for the dental services. You say that the services are preventive in nature and should
be covered. The Plan denied your request. The Plan says the periodic oral evaluation and the periapical x-ray
are not listed as covered services.
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 oral exam and periapical x-ray are
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
periodic oral evaluation (D0120) and the initial periapical x-ray (D0220) provided on December 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an oral exam (D0150) provided October 30, 2019.
You asked the Plan to pay for the oral exam. You say that the services were medically necessary. The Plan denied your request. The Plan says the benefit has been exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers two oral exams a year. We looked at the file, and Medicare rules. Two oral exams were already provided in 2019. Based on this information, we decided that the Plan's rules for coverage of the oral exam have not been met. Therefore, we decided that the Plan does not have to pay for an oral exam (D0150) provided October 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc injections.
You asked the Plan to pre-approve the injections. You say that you were never told that you had to pick up the medication from the pharmacy. The Plan denied your request. The Plan says buy-and-bill injectables are not covered.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Synvisc injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental services (D0220, D2740) provided December 16, 2019.You asked the Plan to pre-approvethe dental services. You say that the services were medically necessary.The Plan denied your request. The Plan says the provider has opted out of Medicare participation.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. The plan only covers services provided by network providers.Therefore, we decided that the Plan does not have to pre-approvedental services (D0220, D2740) provided December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe three additional core buildups, including any pins when required, and three crowns provided on November 14, 2019.You asked the Plan to pay forthe additional core buildups and crowns. You say that the enrollee was given 4 temporary crowns and was advised to come back at a later date for the permanent crowns. You also say that the provider is delaying placing the enrollee's front teeth which is causing eating issues for the enrollee.The Plan denied your request. The Plan says core buildup is not a covered service. The Plan alsosays that the benefits for crowns have been satisfied and the frequency limitation has been exceeded.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, core buildups are not among those covered under this benefit. The documentation shows that the Plan made an exception and processed one core buildup according to the Plan's negotiated rate. The contract also clearly states that crowns are limited to one procedure per calendar year. The record shows that the enrollee received a total of 4 crowns on November 14, 2019, one of which was covered by the Plan, and the enrollee's crown benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe three additional core buildups, including any pins when required, and three crowns provided on November 14, 2019.Your complaint about the enrollee's issues with the rendering provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.