Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on March 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services could have been performed 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 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 services. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on March 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on August 7,
2019.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or
medical records (signed by the ordering physician); therefore, the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be
covered.
The documentation submitted did not include a physician order/lab requisition or medical records stating
exactly tests were to be performed. 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 drug testing
services provided to the enrollee on August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the arthrocentesis provided on October 8, 2019.
You asked the Plan to reduce the copayment for the arthrocentesis. You say that you have had these injections in the past and have only had to pay a coinsurance amount. 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 $275 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $275 copayment for the arthrocentesis.
You have been asked to pay a $217 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows arthrocentesis is considered a surgical procedure and not a Part B drug injection.
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 reduce the copayment for the arthrocentesis provided on October 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe retreatment of previous root canal therapy provided on July 15, 2019.You asked the Plan to pay forthe retreatment of previous root canal therapy. You say that you needed this service because you were in intense pain.The Plan denied your request. The Plan says this service 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. The contract clearly states that retreatment of root canals is not covered.Therefore, we decided that the Plan does not have to pay forthe retreatment of previous root canal therapy provided on July 15, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan of extremity veins; complete bilateral study (93970) and a duplex scan of extremity veins; unilateral or limited study (93971).
You asked the Plan to pre-approve a duplex scan of extremity veins; complete bilateral study and a duplex scan of extremity veins; unilateral or limited study. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that objective testing of peripheral venous function is considered not reasonable and necessary and therefore noncovered under certain circumstances. 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 a duplex scan of extremity veins; complete bilateral study and a duplex scan of extremity veins; unilateral or limited study. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no evidence of signs or symptoms of peripheral vascular disease. There is no evidence of a need for vascular access for hemodialysis or vein grafts for bypass surgery. Therefore, the documentation does not support that the requested test is medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a duplex scan of extremity veins; complete bilateral study and a duplex scan of extremity veins; unilateral or limited study have not been met. Therefore, we decided that the Plan does not have to pre-approve a duplex scan of extremity veins; complete bilateral study (93970) and a duplex scan of extremity veins; unilateral or limited study (93971).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital admission for the enrollee.You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary.The Plan denied your request. The Plan says that there is no evidence of dehydration, severe vomiting, problems with heart or blood pressure, confusion, or pregnancy.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file,and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay for inpatient hospital admission for the enrollee.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on July 31, 2019.
You asked the Plan to waive the copayment for the MRI. You say that you should not be responsible for the copayment because the equipment was unable to take the picture properly. You say the doctor could not read the image. 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 $250 copayment for advanced imaging services (e.g., MRI, CT, PET scans, and stress tests). You have been asked to pay a $250 copayment for the MRI. The MRI 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 copayment for the MRI provided on July 31, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Medicare Part B prescription drugs and medical supplies provided on July 25, 2019.
You asked the Plan to waive the coinsurance for these services. You say that everything should have been included in the outpatient copayment. The Plan denied your request. The Plan says that the coinsurance was 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 20% coinsurance for Medicare-covered Part B drugs and Medicare-covered medical supplies. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-covered Part B drugs and Medicare-covered medical 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 the Medicare Part B prescription drugs and medical supplies provided on July 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea prefabricated porcelain crown for a primary tooth (D2929).You asked the Plan to pre-approvethe dental service. You say that you feel the plan is discriminating you against you based on the denial that you received. You say that the plan will not cover a crown on your coupled baby teeth. You also say that it is not your fault that you were born with defective teeth.The Plan denied your request. The Plan says the prefabricated porcelain crown for a primary tooth is not listed as 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, a prefabricated crown for a primary tooth is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea prefabricated porcelain crown for a primary tooth (D2929).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral or facial photographic image (D0350) and the 2 resin based composites, 1 surface, for anterior teeth (D2330) provided on September 12, 2019.You asked the Plan to pay for the dental services. You say that you had broken teeth. You say that the broken teeth needed to be filled. You also say that you needed to go back to have the filling filed down.The Plan denied your request. The Plan says the 2D oral or facial photographic image and the resin based composite 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 dental services you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the 2D oral or facial photographic image(D0350) and the 2 resin based composites, 1 surface, for anterior teeth (D2330) provided on September 12, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Linzess 290 mcg capsule for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B drugs.
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 Linzess 290 mcg capsule for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on October 9, 2019.
You asked the Plan to pay for the dental services. You say that you cannot afford to pay the bill that you received. You also say that the staff at the provider's office deceived you due to your language barrier. The Plan denied your request. The Plan says the oral evaluation and x-rays that you received 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 x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on October 2, 2019.You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided on October 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator provided on October 12, 2019, by an out of network provider.You asked the Plan to pay for the oxygen concentrator. You say that the enrollee wants to continue to receive oxygen services from Right Healthcare.The Plan denied your request. The Plan says they have in-network suppliers for oxygen services and you did not request 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the oxygen concentrator provided on October 12, 2019, by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Dexcom continuous glucose monitor (CGM) (K0554) and supplies (K0553).You asked the Plan to pre-approvea Dexcom CGM and supplies. You say that this item would help you to better manage your diabetes.The Plan denied your request. The Plan says the criteria for coverage of this item have not been met.The Plan must follow Medicare rules. Medicare rules say that CGM devices are covered for enrollees who are insulin-treated with multiple (three or more) daily injections of insulin. We looked at the file and Medicare rules. The record shows that you are currently insulin-treated with two daily injections of insulin, which is less that the three required for coverage of a CGM. Based on thisinformation, we decided that Medicare rules for coverage of a Dexcom CGM and supplies have not been met.Therefore, we decided that the Plan does not have to pre-approvea Dexcom continuous glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve general anesthesia for a dental examination.You asked the Plan to pre-approve the general anesthesia. You say that the enrollee has difficulty when at the dentist and needs to be under anesthesia.The Plan denied your request. The Plan says this service is not a covered benefit. The Plan also says that the enrollee's coverage does not provide dental anesthesia benefits.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approve general anesthesia for a dental examination.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive periodontal evaluation (D0180), the bitewing x-rays (D0272), and the periodontal maintenance (D4910) provided on October 22, 2019.You asked the Plan to pay forthe dental services. You say that you were advised by a plan representative that you had only received 1 periodontal maintenance in 2019. You also say that you do not remember receiving x-rays at your previous dental appointment on May 30, 2019.The Plan denied your request. The Plan says the frequency limit of 2 exams per plan year has been exceeded. The Plan says the frequency limit of 1 set of bitewing x-rays per plan year has been exceeded. The Plan also says that thefrequency limit of 2 periodontal maintenance procedures per plan year 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, the frequency limits have been reached for the services that you received. The record shows that the Plan previously paid for an oral exam and periodontal maintenance that you received on January 24, 2019. Additionally, the Plan paid for an oral exam, bitewing x-rays, and periodontal maintenance that you received on May 30, 2019.Therefore, we decided that the Plan does not have to pay forthe comprehensiveperiodontal evaluation (D0180), the bitewing x-rays (D0272), and the periodontal maintenance (D4910) provided on October 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lanso/amox/clar pack for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee needs this for her H. Pylori infection.
The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 the lanso/amox/clar pack
for the enrollee.
Benefits for this drug 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient services you received on September 25, 2019, and October 2, 2019.You asked the Plan to waive the coinsurance. You say that you cannot pay the coinsurance.The Plan denied your request. The Plan says you received the services from an out-of-network provider.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 40% coinsurance for outpatient hospital services and diagnostic tests. Review of the file shows that you were provided out-of-network outpatient hospital services and diagnostic tests on September 25, 2019, and October 2, 2019. You have been asked to pay a 40% coinsurance for the services. The services fall within the out-of-network outpatient hospital 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 coinsurance for the outpatient services you received on September 25, 2019, and October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient services you received on September 25, 2019, and October 23, 2019.
You asked the Plan to waive the coinsurance. You say that you cannot afford the coinsurance. The Plan denied your request. The Plan says you are responsible for the cost share.
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 40% coinsurance for out-of-network outpatient services and diagnostic tests. Review of the file shows that you were provided out-of-network outpatient services on September 25, 2019, and October 23, 2019. You have been asked to pay a 40% coinsurance for the services. The services fall within the out-of-network outpatient diagnostic 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 coinsurance for the outpatient services you received on September 25, 2019, and October 23, 2019.