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

We decided that the Plan does not have to pay forthe comprehensive oral evaluation, prophylaxis, panoramic x-ray, and bitewings provided on December 10, 2019 by an OON provider.You asked the Plan to pay forthe comprehensive oral evaluation, prophylaxis, panoramic x-ray, and bitewings. You say that these services should be covered because your plan includes coverage for one exam, x-ray, and preventive cleaning per year.The Plan denied your request. The Plan says the treating provider is an OON provider for the supplemental preventive dental 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 covered when they are received OON.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation, prophylaxis, panoramic x-ray, and bitewings provided on December 10, 2019 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.You asked the Plan to pre-approve these services. You say that the PET is needed to check for tumors.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has diarrhea, a question of pancreatic insufficiency, and elevated chromogranin. Cancer is not strongly suspected and a PET/CT is not a screening modality. The records do not support that the requested PET/CT is reasonable or medically necessary for the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the PET scan provided on January 2, 2020.
You asked the Plan to waive the copayment for the PET scan. You say that you weren't asked to pay at the time
of service. You say that you should not owe the balance. The Plan denied your request. The Plan says the
copayment 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 $225
copayment for each in-network, Medicare-covered advanced imaging service.
You have been asked to pay a $225 copayment for the PET scan. The PET 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 for the PET scan provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits provided from June 6, 2019 to August 8, 2019.
You asked the Plan to waive the copayments for the specialist office visits. You say that the copayments are a financial hardship. 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 $35 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You have been asked to pay a $35 copayment for each of the specialist office visit. The specialist office visits fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for specialist office visits provided from June 6, 2019 to August 8, 2019.
Your complaint that the office visits were a result of a surgical complication 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for hand wrist orthosis (L3916) provided on January 17, 2020.
You asked the Plan to pay for the hand wrist orthosis. You say that you would like reconsideration because the
billed supply is medically necessary. The Plan denied your request. The Plan says the documentation submitted
does not support that the physician discussed the need for the supplied code with the provider.
The Plan must follow Medicare rules. Medicare rules say that for any DMEPOS item to be covered by
Medicare, the patient's medical record must contain 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 or
replacement (if applicable).
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the hand wrist orthosis have not been met. Specifically, the record indicates that the Plan requested
progress notes to indicate the provider discussed the need for the billed supply code along with documentation
of the duration of the patient's condition, clinical course (worsening or improving), prognosis, nature and
extent of functional limitations, other therapeutic interventions and results, and previously purchased DME
items related to the billed items. There is insufficient information to verify the billed supply code. Therefore,
we decided that the Plan does not have to pay for hand wrist orthosis (L3916) provided on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided out of network on January 27,
2020.
You asked the Plan to pay for out of network providers. You say that this service should be covered by the
Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 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 medical services provided out of network.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forinfectious agent disease testing with procedure code 87798 provided on February 10, 2020.You asked the Plan to pay forlab test. You say that this testing was medically necessary as ordered by theenrollee's provider.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not covered by Medicare for the diagnosis listed.The Plan must follow Medicare rules. Medicare rules say that procedure code 87798 is only covered for certain, specific diagnosis codes. Diagnosis code N39.0 is not among those for which procedure code 87798 is covered by Medicare.We looked at the file and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of lab test have not been met.Therefore, we decided that the Plan does not have to pay forinfectious agent disease testing with procedure code 87798 provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an office visit provided while outside of the Plan's service area on December 31, 2019.You asked the Plan to pay for office visit. You say that you are hoping that these claims will be covered under the Plan's passport benefits.The Plan denied your request. The Plan says that the denial of payment for these services is correct, because you did not have passport benefits on this date of service and these services were obtained from an out-of-network, out-of-area provider.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care,renal dialysis, and pre-approved care.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit medical records or any documented attempts to obtain medical records for this service. Without this information, we cannot determine whether the service you received meets the Medicare criteria for urgent, out-of-area care. Therefore, the Plan has not shown that its denial of payment is correct or justified based on Medicare rules or the Plan contract. Therefore, we decided that the Plan has to pay for an office visit provided while outside of the Plan's service area on December 31, 2019.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 pay for the computerized corneal topography rendered on January 14, 2020. 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 were not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee reported complaints of blurred vision and difficulty reading on February 10, 2020. Examination showed bilateral nuclear and cortical cataract. Corneal topography was performed, but interpretation is absent from the record. The diagnosis was bilateral cataract and plan was made for cataract surgery. Diagnostic corneal topography was not medically necessary. The enrollee's complaints, examination findings, and diagnosis of cataract did not warrant testing with corneal topography, and in most cases,it is not the standard of care for cataract evaluation. Although the enrollee had previous LASIK and evidence of that surgery on corneal exam, there was no documentation suggesting corneal disease was related to the enrollee's complaints or diagnoses. There was no diagnosis or interpretation present that would support a medical need for topography.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the computerized corneal topography rendered on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eyeglasses and frames purchased on February 5, 2020.You asked the Plan to pay forthe vision services. You say that you received a check for $100. You purchased from an in-network facility that is listed on the website as an authorized provider. Therefore your reimbursement should be $200.The Plan denied your request. The Plan says this claim was processed correctly.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when Medicare does not cover vision services. The Plan covers limited vision services. The records provided show that you were given the choice to filing with insurance or taking the discount. You chose to take the discount. Therefore, the Plan is not required to provide any further reimbursement for these vision services. We looked at the file and the Plan's rules. Enrollee's cannot combine benefits with any discount, promotional offer or other group benefit plans. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay forthe eyeglasses and frames purchased on February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable gaseous oxygen system purchased on January 16, 2020 from an out of network provider.You asked the Plan to pay for the portable gaseous oxygen system. You say that the hospital would not let you leave without an oxygen system.The Plan denied your request. The Plan says 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 item at issue in this appeal. The Plan did not pre-approve the item at issue.Purchased oxygen equipment is not covered by Medicare.We found no exception that would require the Plan to pay for this item.Therefore, we decided that the Plan does not have to pay for the portable gaseous oxygen system purchased on January 16, 2020 from an out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after June 16, 2020.You asked the Plan to pre-approve continued SNF coverage. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.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 continued SNF coverage. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you had stable vital signs. You received oral medications. You required stand-by assistance with functional mobility including walking short distances. The documentation does not support that you require the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, you no longer require the necessary services on an inpatient basis, at a SNF level of care
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from January 9, 2020 to
January 24, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you 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 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 physician's services provided from January 9, 2020 to January
24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from November 29, 2019 to December 28, 2019. You asked the Plan to pay for SNF care. You say that this should be covered by Medicare. The Plan denied your request. The Plan says this was not necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found for the dates at issue, the enrollee had no identifiable skilled nursing or therapy service needs. The enrollee did not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from November 29, 2019 to December 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the osteogenesis stimulator provided on
October 21, 2019.
You asked the Plan to waive the coinsurance for the osteogenesis stimulator. You say that you were informed it
would be no cost to you. You say that the machine did not work or help. The Plan denied your request. The
Plan says the coinsurance 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 20%
coinsurance for Medicare-covered items.
You have been asked to pay $595.60, which is 20% coinsurance of the allowed amount for the osteogenesis
stimulator. The allowed amount is $2,978.02 (20% x $2,978.02 = $595.60). The osteogenesis stimulator falls
within the "Durable medical equipment (DME) and related 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 osteogenesis stimulator provided on October 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore build up and nitrous oxide.You asked the Plan to pre-approvecore build up and nitrous oxide. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are 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.Therefore, we decided that the Plan does not have to pre-approvecore build up and nitrous oxide.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic services (CPT 99210, CPT 97530) provided to you on January 28, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.The Plan must follow Medicare rules. The rules saythat the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have topay forthe chiropractic services (CPT 99210, CPT 97530) provided to you on January 28, 2020.