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

We decided that the Plan does not have to waive the copayment fora duplex scan provided on May 14, 2019.You asked the Plan to waive the copayment fora duplex scan. You say that this should be considered a screening and you should not be responsible for 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 enrolleesin 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 $150 copayment for diagnostic procedures and tests. You received a duplex scan on May 14, 2019. A duplex scan is considered diagnostic, not preventative, and you are responsible to pay the $150 copayment. You have been asked to pay a $150 copayment for a duplex scan. A duplex scan 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 fora duplex scan provided on May 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the eyeglasses.
You asked the Plan to pre-approve the eyeglasses. The Plan denied your request. The Plan says per your vision
plan it has not been two years since you received eyeglasses.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services every 2 years.
We looked at the file and the Plan's rules. The file shows you received new eyeglasses in September 2019. The
eyewear benefit is limited to one pair of eyeglasses every 2 years. Therefore, we decided that the Plan does not
have to pre-approve the eyeglasses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided by provider on August 22, 2019.You asked the Plan to pay for the knee orthosis (L1851) and suspension sleeve (L2397). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says rules for telehealth services were not met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided by provider on August 22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on December 4, 2018.You asked the Plan to pay for train of four testing. You say that this was medically necessary.The Plan denied your request. The Plan says this service is bundled into the payment of another procedure.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 95999 is not supported in the medical record.  Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met.Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on December 4, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on June 28, 2019.
You asked the Plan to pay for the orthosis. 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. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on June 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two crowns, two core buildups, pontic, adjunctive
procedure provided on April 2, 2019 and April 18, 2019.
You asked the Plan to pay for the crowns, core buildups, pontic, adjunctive procedure. You say that these
services provided to the enrollee were medically necessary to have done prior to her hip surgery. You also say
that the enrollee was required to have her teeth cleaned prior to surgery and a cavity was discovered within the
bridge. The Plan denied your request. The Plan says crown, core buildup, pontic, and adjunctive procedure are
not covered services. provider.
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, these items or services are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two crowns,
two core buildups, pontic, adjunctive procedure provided on April 2, 2019 and April 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe shoulder-elbow-wrist-hand orthosis provided on May 1, 2019.You asked the Plan to pay forthe shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says criteria for the orthosis was not met.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 shoulder-elbow-wrist-hand orthosis (L3960). Our physician reviewer found thedocumentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessaryfor the enrollee in this case,as there is no documentation of a physicalexamination of the shoulder.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 shoulder-elbow-wrist-hand orthosis (L3960) have not been met.Therefore, 
we decided that the Plan does not have to pay forthe shoulder-elbow-wrist-hand orthosis provided on May 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveextractions of erupted tooth requiring removal of bone and/or sectioning of tooth (code D7210 x7) and extractions of erupted tooth or exposed root (code D7140 x10).You asked the Plan to pre-approvethe extractions. The Plan denied your request. The Plan says these procedures have exceeded the frequency limitation under your 2019 supplemental dental plan 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, extractions are limited to up to 3 per calendar year. The record shows that you received 3 extractions on December 6, 2019 and your extractions benefit was then exhausted.Therefore, we decided that the Plan does not have to pre-approveextractions of erupted tooth requiring removal of bone and/or sectioning of tooth (code D7210 x7) and extractions of erupted tooth or exposed root (code D7140 x10).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmological services provided on September 3, 2019.You asked the Plan to waive the copayment for the ophthalmological services. The Plan denied your request. The Plan says the correct cost share was applied to the claim.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 $50 copayment for vision care, Medicare-covered exams.You have been asked to pay $50 copayment for the ophthalmological services. The ophthalmological servicefalls within the vision care, Medicare-covered exam 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 ophthalmological services provided on September 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the a mammogram (77067) provided on August 8, 2019 by an out of network provider.
You asked the Plan to pay for the mammography. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. The plan has in-network providers that can provide the same 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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the a mammogram (77067) provided on August 8, 2019 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional $4,198 for hearing aids provided on July 8, 2019.You asked the Plan to pay additional $4,198 for hearing aids. You say that you cannot afford to pay for the hearing aids and you are asking the Plan to help. The Plan denied your request. The Plan says the full $600 benefit allowance has been issued on this claim.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 inthis case.We looked at the file and the Plan's rules. The file shows that the Plan paid the full benefit allowance of $600 for the hearing aids. Therefore, we decided that the Plan does not have to pay an additional $4,198 for hearing aids provided on July 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Praluent 75 MG/ML Pen.You asked the Plan to pre-approve Praluent. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says Praluent 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 a Praluent 75 MG/ML Pen.Benefits for Praluent 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.You asked the Plan to pre-approve a shower chair. You say that you were told that the shower chair was a covered benefit. You say that you need the shower chair for bathing assistance.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Buprenorphine 10 MCG/HR Patch.You asked the Plan to pre-approve Buprenorphine. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says Buprenorphine 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-approvea Buprenorphine 10 MCG/HR Patch.Benefits for Buprenorphinemay be available under Medicare Part D.Contactthe 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 outpatient clinic visit (G0463) provided on April 11, 2019 by out of network provider.You asked the Plan to pay forthe clinic visit. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not emergent or preauthorized. There are in-network providers that can provide the service at issue.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 forthe outpatient clinic visit (G0463) provided on April 11, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve high frequency chest wall oscillation device(HFCWOD) (E0483).You asked the Plan to pre-approvethe HFCWOD. You say that you were diagnosed with COPD which has worsened over the years and due to the increased worsening condition the device is medically necessary for you.The Plan denied your request. The Plan says this device is not medically  necessary as the enrollee does not have medical conditions such as cystic fibrosisor a disease of the nerves or muscles or bronchiectasis diagnosed by CT scan.The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.The record does not show that you have cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that you do not have a medical condition for which a high frequency chest wall oscillation devise can becovered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvehigh frequency chest wall oscillation device(HFCWOD) (E0483)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis (L1833) and suspension sleeve (L2397) provided on September 25, 2019.You asked the Plan to pay for the orthoses. You say that the medical records provided support the necessity of the services in dispute.The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician. There is no evidence of a prior telehealth service with the ordering physician. The deliver ticket submitted did not include the carrier's tracking number. The proof of delivery did not include an order number or details to corroborate the delivery ticket and the proof of deliver is not itemized to indicate the specific supplies.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are 
likewise non-covered.Therefore, we decided that the Plan does not have to pay forthe knee orthosis (L1833) and suspension sleeve (L2397) provided on September 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on September 13, 2019.
You asked the Plan to reimburse you for the hearing aids. You say that the Plan's provider does not have powerful enough hearing aid to help you. The Plan denied your request. The Plan says coverage for hearing aids must be provided by one specific provider.  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. The Plan pays for hearing aids only when provided by
one specific provider.  We looked at the file and the Plan's rules. The provider you used is not a Plan hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on September 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe cardiovascular ultrasound or the stress test provided on November 30, 2018 to December 26, 2018.You asked the Plan to waive the copayment fora cardiovascular ultrasound and the stress test. You say that you are on Social Security Disability and after you pay rent, utilities, food, and transportation, you have nothing left.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 an $80 copayment for each diagnostic radiology service. You have been asked to pay an $80 copayment for a cardiovascular ultrasound and an $80 copayment for the stress test. The cardiovascular ultrasound and the stress test fall 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 forthe cardiovascular ultrasound or the stress test provided on November 30, 2018 to December 26, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a golf/driving range fitness membership provided from March 14, 2019 to May 31, 2019.You asked the Plan to reimburse you for the golf/driving range fitness membership. You say that the Plan should reimburse you based on the receipts you submitted showing you paid your fees and you played golf. The Plan denied your request. The Plan says you did not submit itemized receipts or proof of payment to show that you paid for the service.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because you did not submit itemized receipts or proof of payment to show that you paid for the service.Therefore, we decided that the Plan does not have to reimburse you for a golf/driving range fitness membership provided from March 14, 2019 to May 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the periodontal scaling and root planing, one to three teeth per quadrant (D4342), for the upper left and upper right quadrants.You asked the Plan to pre-approve the dental services. You say that the Plan has covered periodontal scaling and root planing for a full quadrant, but not the 3 extractions.The Plan denied your request. The Plan says periodontal scaling and root planing for 1 to 3 teeth per quadrant 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, the periodontal scaling and root planing for 1 to 3 teeth per quadrant are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve the periodontal scaling and root planing, one to three teeth per quadrant (D4342), for the upper left and upper right quadrants.