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

We decided that the Plan does not have to pre-approvea consultation and three extractions to be provided by an oral surgeon.You asked the Plan to pre-approvethe consultation and extractions. You say that you have a heart condition, and if you have dental issues you will have a heart attack.The Plan denied your request. The Plan says your Health Plan only covers dental services provided by a participating general dentist. The Plan also says that consults and extractions performed by oral surgeons are not covered.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 provided by Oral Surgeons, Periodontists, Endodontists, other dental specialists or non-network General Dentists are not covered.Therefore, we decided that the Plan does not have to pre-approvea consultation and three extractions to be provided by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lumbar injection and epidural injection provided on January 29, 2020 and February 4, 2020. You asked the Plan to waive the copayment for the lumbar injection and epidural injection. You say that each time you were treated as an outpatient and not admitted to the hospital. You say that the charges are out of proportion for the procedures. The Plan denied your request. The Plan says the copayments 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 $450 copayment for surgery services at an in-network outpatient hospital. You have been asked to pay a $450 copayment for each injection. The total amount you owe is $900 ($450/injection x 2 injections = $900). The lumbar injection and epidural injection fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the outpatient copayment was applied. 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 lumbar injection and epidural injection provided on January 29, 2020 and February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on March 5, 2020.You asked the Plan to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service.The Plan denied your request. The Plan says payment for this service is included in the DRG.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist office visit and the Part B injection provided on November 6, 2019.
You asked the Plan to waive the cost share for the specialist office visit and the Part B drug injection. You say that you thought this was your annual exam. 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 per visit for Medicare-covered specialty care services and 20% of the total cost for other Medicare-covered Part B prescription drugs. You have been asked to pay a $35 copayment for the specialist office visit. You have also been asked to pay $183.69 which is 20% of the allowed amount for the Part B drug injection. The allowed amount is $918.45. ($918.45 x 20% = $183.69). The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Part B drug injection falls within the "Medicare Part B prescription drugs" benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the specialist office visit and the Part B injection provided on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on November 22, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says services from non-participating providers are not covered under the enrollee's Plan unless they are authorized by the Plan before the services are provided.
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 nurse practitioner services provided on November 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair accent wheel color or upgraded electronics.
You asked the Plan to pre-approve the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), Expandable controller (E2377), and accent wheel color. You say that you need a Group 3 power wheelchair, accessories, accent wheel color, and upgraded electronics so you can get out of bed and get to appointments. The Plan denied your request. The Plan says the electronic upgrades cannot be covered as it is not medically necessary to control the three approved power options through the joystick and the color kit does not serve a medical purpose.
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. Upper limb strength and range of motion are adequate for you to be able to control the power options using their own switches which are included in the allowance of these power options. The color kit does not serve a purpose that is primarily medical in nature.
Based on this information, we decided that Medicare rules for coverage of the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), Expandable controller (E2377), and accent wheel color have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair accent wheel color or upgraded electronics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dental services (D5213, D5214) rendered July 26, 2019.
You asked the Plan to waive the coinsurance for the dental services. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost-sharing has been applied.
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 50% coinsurance for Comprehensive Dental Services. You have been asked to pay a 50% coinsurance for the dental services. The dental services at issue fall within the Comprehensive Dental 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 dental services (D5213, D5214) rendered July 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections (J0585).
You asked the Plan to pre-approve Botox. You say that Botox is medically necessary for relief of Raynaud's Syndrome related pain. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Botox. Our reviewer says that the requested injections are not medically necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved compendia there is no data to support that the Botox is medically reasonable and necessary for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox injections (J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 2, 2020 by an out of network (OON) provider.You asked the Plan to pay for physician services. You say that you would like the Plan to pay for these services because it will cause less money in the long term.The Plan denied your request. The Plan says prior authorization was not obtained for these 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 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 physician services provided on January 2, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the hearing aids to be purchased from an out of network vendor.You asked the Plan to pre-approve the hearing aids. You say that you used to be able to use another vendor and the plan would pay for a portion for the item every 3 years. Now they won't pay for any of them.The Plan denied your request. The Plan says hearing aids that are not TruHearing branded hearing aids are not covered by the plan. 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 The benefit is limited to TruHearing's advance and premium hearing aids. You must see a TruHearing provider to use this benefit. We looked at the file and the Plan's rules. 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 pre-approve the hearing aids to be purchased from an out of network vendor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on February 4, 2019. You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records to verify the services billed. The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on February 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions (D7210) on teeth 18, 19, and 22.
You asked the Plan to pre-approve dental extractions. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you have exhausted this dental benefit for the 2020 calendar year.
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 beyond three procedures per calendar year. The contract with the Plan clearly says that dental extractions are limited to three per calendar year and the file shows that you were approved for three dental extractions on teeth 27, 28, and 29 on July 2, 2020. The requested dental extractions on teeth 18, 19, and 22 would exceed the dental benefit limit. Therefore, we decided that the Plan does not have to pre-approve dental extractions (D7210) on teeth 18, 19, and 22.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing rendered on October 3, 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 claim was not billed correctly.The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479.The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 testing rendered on October 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the out-of-network gym membership from January 1, 2019 through July 1, 2019.
You asked the Plan to reimburse for the gym membership. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says valid proof of payment was not submitted with the out-of-network claim form.
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. Valid proof of payment was not submitted with the out-of-network claim form. The Plan states the claim will be reconsidered once proof of payment is received. Your EOC states, to be reimbursed, submit an out-of-network reimbursement form, a fitness facility member verification form, and paid receipts directly to Customer Service. Therefore, we decided that the Plan does not have to reimburse for the out-of-network gym membership from January 1, 2019 through July 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on September 17, 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 procedure code 99291 is not supported.
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 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of
30-74 minutes of critical care spent on the enrollee. 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 critical care services rendered on September 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedisposable gloves.You asked the Plan to pre-approvedisposable gloves. You say that you need gloves to prevent COVID-19 but do not have the resources to obtain them.The Plan denied your request. The Plan says gloves are not paid separately underMedicare Part B.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Non-sterile disposable gloves are only covered by Medicare for home self-dialysis or Home Health Services package.Therefore, we decided that the Plan does not have to pre-approvedisposable gloves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee needs the incontinence supplies which were previously covered. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 3, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 the laboratory services are not supported in the medical record. Specifically, the place of service
on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The
submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81;
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained
in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage
of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the
laboratory services provided on October 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide Juvederm.
You asked the Plan to provide Juvederm. You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says the drug is not approved for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 provide Juvederm. Our reviewer says that criteria for the drug is not met. Our physician reviewer found this appeal considers the medical necessity for the requested Juvederm for the treatment of chronic dysphagia related to paralysis of vocal cords and larynx. Submitted documentation, Medicare guidelines and Medicare approved compendia were considered. A review of compendia does not support Juvederm is FDA approved or a recognized off label use for the enrollee's condition. Without the support of the documentation, Medical necessity cannot be determined. The denial is upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Juvederm have not been met. Therefore, we decided that the Plan does not have to provide Juvederm.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fortravel expenses (S9975, S9999) incurred from February 7, 2020 to February 8, 2020.You asked the Plan to pay fortravel expenses. You say that this should be covered.The Plan denied your request. The Plan says these expenses are not related to a transplant service.The Planmust follow Medicare rules. Medicare rules say that that in any circumstance in which an MA plan provides transplant services at a more distant location, the MA plan mustprovide reasonable transportationand accommodations for the enrollee and a companion while in the distant location for medical care.We looked at the file and Medicare rules.The record does not show that any transplant services took place from travel expenses (S9975, S9999) incurred from February 7, 2020 to February 8, 2020or that the Plan provided said services.Based on this information, we decided that Medicare rules for coverage of travel expenses have not been met.Therefore, we decided that the Plan does not have to pay fortravel expenses (S9975, S9999) incurred from February 7, 2020 to February 8, 2020.