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

We decided that the Plan does not have to pre-approve crowns (D2791) for teeth # 27 and 28. You asked the Plan to pre-approve the dental services. You say that the crowns are broken. You say that the quality of the material of the crowns is not good. You also say that you are having a hard time eating. The Plan denied your request. The Plan says crowns are limited to coverage once every 60 months per tooth. The Plan also says that the frequency limit has been reached. 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 and crowns are a covered service, the frequency limit has been reached. The record shows that the Plan paid for crowns for teeth # 27 and 28 that you received on July 14, 2018. Therefore, we decided that the Plan does not have to pre-approve crowns (D2791) for teeth # 27 and 28.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered tothe enrollee on October 22, 2019.
You asked the Plan to pay for these 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 for the special pump services rendered tothe enrollee on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology services. You asked the Plan to pre-approve the oncology services. The Plan denied your request. The Plan says the requested oncology services are available with 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve oncology services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by you. You asked the Plan to pre-approve the physician's services. You say the services are based on continuity of care that was established in 2018. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 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 services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a spinal canal injection provided on July 30, 2019.
You asked the Plan to waive the copayment for a spinal canal injection. You say that you were told that the charges would be covered by the Plan. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. The enrollee received a spinal canal injection on July 30, 2019. A spinal canal injection is considered an outpatient surgical procedure. Therefore, the enrollee is responsible to pay the $295 copayment. The enrollee has been asked to pay a $295 copayment for a spinal canal injection. A spinal canal injection falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 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 copayment for a spinal canal injection provided on July 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second authorization for a Respironics brand CPAP machine. You asked the Plan to pre-approve another authorization for a CPAP machine. You say that the Plan approved a ResMed brand CPAP machine and you want an authorization for a Respironics brand CPAP machine. The Plan denied your request. The Plan says a second authorization is not necessary because you are approved for either brand. The Plan must follow Medicare rules. Medicare rules say that items and services that are medically necessary are covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of authorization for another CPAP machine is not necessary. Therefore, we decided that the Plan does not have to pre-approve a second authorization for a Respironics brand CPAP machine.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant 360 testing provided to the enrollee on October 7, 2019. You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says this testing was for screening purposes not covered by Medicare. The Plan follows Medicare rules. The rules explicitly say that screening tests, except for the few tests listed above, are not covered. The test at issue in this appeal, this testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for Guardant 360 testing provided to the enrollee on October 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction of an erupted tooth or root (D7140 x 2) provided on October 23, 2019.
You asked the Plan to pay for the dental service. You say that the provider is in network. You also say that the services should be covered. The Plan denied your request. The Plan says the cost sharing amounts were applied correctly. The Plan says the deductible must be met in order for covered services to be paid. The Plan also says there is a 50% coinsurance for extractions received in network.
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 and extractions are a covered service, the deductible must be met before coverage for services begins. Additionally, there is a 50% coinsurance for extractions received in network.
Date of Service
CPT Code
Billed Amount
Allowed Amount
Deductible
Cost Share (50%)
Plan Paid
Your Responsibility
10/23/2019
D7140
$145
$65
$65
$0
$0
$65
10/23/2019
D7140
$145
$65
$35
$15
$15
$50
TOTAL:
$100
$15
$15
$115
Cost sharing amounts are a contractual obligation of the Plan and cannot be waived. Therefore, we decided that the Plan does not have to pay for the extraction of an erupted tooth or root (D7140 x 2) provided on October 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter. You asked the Plan to pre-approve a power scooter. You say that you need this to get to doctor appointment. The Plan denied your request. The Plan says power scooters are non-covered for use outside the home. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch Verio test strips.You asked the Plan to pre-approve the non-preferred brand of test strips. You say that the enrollee wants to use the non-preferred brand. The Plan denied your request. The Plan says there is no medical reason the enrollee is unable to use the Plan preferred meters. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no physician documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve OneTouch Verio test strips.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a sleep study provided on July 11, 2018. You asked the Plan to waive the coinsurance for a sleep study. You say that services were rendered over a year ago and 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 20% coinsurance for diagnostic procedures and tests. You had a sleep study on July 11, 2018. The allowed amount is $155.76 and 20% of that is $31.15. You have been asked to pay the total coinsurance amount of $31.15 for a sleep study. A sleep study 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 coinsurance for a sleep study provided on July 11, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you really need this item every time you leave the house because you are supposed to be on oxygen full-time. The Plan denied your request. The Plan says that Medicare does not cover equipment for use outside the home.
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-approve a portable oxygen concentrator.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mental health therapy to be provided.
You asked the Plan to pre-approve the mental health therapy. You say that this provider specializes in anxiety
and OCD and after attending two therapy sessions, the enrollee feels comfortable with this provider and has
shown progression in reducing the anxiety and compulsive urges she had before. The Plan denied your request.
The Plan says you must receive care from in-network providers with the exception of emergency or urgent care
or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 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 services. Therefore, we decided that the Plan does not have to pre-approve mental
health therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision care services provided on October 25, 2019 by an out of network (OON) provider.
You asked the Plan to pay for vision care services. You say that you do not know what patients you will be seeing. You say that you are contracted by the nursing facility. The Plan denied your request. The Plan says the referring facility is out-of-network. The Plan says that 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 for vision care services provided on October 25, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram provided November 15,
2019.
You asked the Plan to waive the copayment for the mammogram. You say that this mammogram was
performed because of an irregularity on your first mammogram. You say you the second mammogram may not
have been necessary. 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 $110
copayment for outpatient x-rays taken at any other location than in a physician's office. For this date of service,
you have been asked to pay the allowed amount of the claim because this amount is less than the $110
copayment for the mammogram.
You have been asked to pay a $109.42 copayment for the mammogram. The mammogram falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you
received the service.
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 mammogram provided on November 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services including an extraction, denture and implant
(D5820, D7210, D6010) provided September 11 to September 24, 2019.
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the services at issue are not a covered benefit.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services including an
extraction, denture and implant (D5820, D7210, D6010) provided September 11 to September 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device.
You asked the Plan to pre-approve a powered upper extremity range of motion assist device (L8702). You say that with restored arm function the enrollee can be independent in all ADLs and improved balance. The Plan denied your request. The Plan says your request is not medically necessary because this device has deluxe features that exceed the enrollee's needs and replaces, rather than improves the function of the extremity.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary, and are experimental and investigational are not covered. Items and services are furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the enrollee's condition or to improve the function of a malformed body member and one that meets but does not exceed the enrollee's medical need. We looked at the file and Medicare rules. There is insufficient medical record information submitted to show this orthosis would be preferred or more effective than the traditional upper orthosis types that are covered by Medicare. Based on this information, we decided that Medicare rules for coverage of a powered upper extremity range of motion assist device (L8702). have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bi-level positive airway pressure device with back-up rate and heated humidifier for the enrollee.
You asked the Plan to pre-approve bi-level positive airway pressure device with back-up rate and heated humidifier. You say that the enrollee requires these items. The Plan denied your request. The Plan says that this is not covered when the primary diagnosis is obstructive sleep apnea.
The Plan must follow Medicare rules. Medicare rules say that a bi-level positive airway pressure device with back-up rate is not reasonable and necessary if the primary diagnosis is OSA. The rules also say either a non-heated (E0561) or heated (E0562) humidifier is covered when ordered by the treating practitioner for use with a covered PAP (E0470 or E0601) device. We looked at the file and Medicare rules. The file indicates the enrollee's primary diagnosis is OSA and the enrollee does not have a covered PAP. Based on this information, we decided that Medicare rules for coverage of bi-level positive airway pressure device with back-up rate and heated humidifier have not been met. Therefore, we decided that the Plan does not have to pre-approve bi-level positive airway pressure device with back-up rate and heated humidifier for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the services (CPT 23395) provided on August 13, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed code cannot be verified.
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 23395 is "Muscle transfer, any type, shoulder or upper arm; single". 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 services. Our reviewers says that the use of CPT code 23395 is supported by the records provided. Our physician reviewer found that this code is for muscle transfer procedure. The operative report does describe a muscle transfer procedure of the biceps muscle. To cite the operative report; "The biceps tendon was identified and it was noted to have significant tendinopathy/tendinosis. A bicep tenotomy was performed at the level of the future humeral neck cut. A biceps tendon transfer was then performed, and #5 fiberwire sutures were used to transfer the biceps tendon to the pectoralis major tendon." 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 services have been met. Therefore, we decided that the Plan has to pay for the services (CPT 23395) provided on August 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel.
You asked the Plan to pre-approve Enbrel. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Enbrel 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 Enbrel.
Benefits for Enbrel 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 pre-approve physician's services to be provided by provider.You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the Plan does not cover non-emergency services by a non-contracted provider when a contracted provider can do the services. The Plan has many contracted providers that can provide the services you need.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 services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by provider.