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

We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on November 4, 2019 and November 19, 2019. You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 hospital outpatient clinic visit provided on November 4, 2019 and November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transitional care management services provided on October 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for transitional care management services. You say that because the enrollee was not seen in the office it was not possible to get authorization. The Plan denied your request. The Plan says authorization is required for OON 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 the transitional care management services provided on October 22, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildups, including any pins when required (D2950) on tooth #'s 2 and 5.
You asked the Plan to pre-approve the core buildups. You say that crowns have already been approved for tooth #'s 2 and 5, and it is likely that these teeth will require core buildups as additional support for the crowns. You also say that core buildups and crowns are both required to achieve the ultimate goal of a secure and stable crown The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit plan.
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 contract clearly states that core buildups (D2950) are not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core buildups, including any pins when required (D2950) on tooth #'s 2 and 5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lens enhancements provided on September 21, 2019.
You asked the Plan to pay for the lens enhancements. You say that you need to have anti-reflective coatings on your lenses due to being light sensitive from having trigeminal and occipital neuralgia and chronic dry eyes. You state that you need lenses that are ultra-light as the weight of the lenses affects your trigeminal neuralgia and facial nerve sensitivity. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. The lens enhancements provided to you are not payable under original Medicare nor your medical coverage as original Medicare only covers vision hardware post cataract removal surgery and the Plan only covers basic routine vision benefits as described on page 105 of the EOC contract. The Plan did not find any unique circumstances that would allow for an exception to allow coverage for lens enhancements under the medical benefit or the routine vision benefit. Medicare does not offer coverage for routine vision hardware. Therefore, we decided that the Plan does not have to pay for the lens enhancements provided on September 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic mammogram provided on October 30, 2019 by an out of network (OON) provider. You asked the Plan to pay for a diagnostic mammogram. You say that these services were necessary. You say
that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a diagnostic mammogram provided on October 30, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthoses and suspension sleeves provided by provider on November 19, 2019.You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee received knee orthoses (L1833) and suspension sleeves (L2397) from a different provider on March 7, 2018.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The orthoses the enrollee already had are still within the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the knee orthoses at issue. Based on the records provided, there is no indication the orthoses provided met Medicare coverage criteria for replacement at the time of issue. Medicare coverage criteria for orthoses replacement were not met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided by provider on November 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says LTACH admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH). Her feeding tube was removed and she was started on IV nutrition. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered to you on October 10, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were not billed correctly.The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.We looked at the file and Medicare rules. The file shows that the claim was not billed with the appropriate primary, first-listed, or principal diagnosis. 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 emergency room (ER) services rendered to you on October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Tetanus vaccination (90471 and 90715) provided on August 8, 2019.
You asked the Plan to pay for the Tetanus vaccination. You say that you would like reconsideration as the vaccination should be covered by the Plan. The Plan denied your request. The Plan says a tetanus vaccination that is related to an accidental puncture wound or injury would be a covered benefit under Part B but there is no diagnosis code on the claim that indicates this information. In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tetanus vaccination. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Tetanus vaccination. Therefore, we decided that the Plan does not have to pay for a Tetanus vaccination (90471 and 90715) provided on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for transitional care management services (99496) provided on October 17, 2019.
You asked the Plan to pay for the transitional care management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says only one TCM service is allowed per beneficiary during the TCM period and only 18 days elapsed between the billed services.
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 99496 is not supported in the record. Specifically, transitional care management codes may only be billed once in the 30-day period. Based on this information, we decided that Medicare rules for coverage of the transitional care management services have not been met. Therefore, we decided that the Plan does not have to pay for transitional care management services (99496) provided on October 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to enrollee on August 29, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered to enrollee on August 29, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve 60mg Prolia.
You asked the Plan to pre-approve the Prolia. You say that you would like reconsideration as Prolia is medically necessary. The Plan denied your request. The Plan says that Prolia is covered under Medicare Part D.
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 the Prolia. Our reviewer says that Prolia is typically covered by Part B. In addition in the EOB it states osteoporosis drugs in setting of fracture related to post-menopausal condition is covered. Our physician reviewer found Prolia is appropriate therapy. 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 Prolia have been met. Therefore, we decided that the Plan has to pre-approve 60mg Prolia.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an ECG provided on September 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an ECG. You say that these services were referred by a contracted provider. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are in-network providers available.
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 an ECG provided on September 24, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the specialist office visits provided from January 7, 2019 to September 9, 2019.You asked the Plan to reduce the copayment for the specialist office visits. You say that this provider is your primary care physician. You say he is also a sports health specialist, but you have not seen him in that capacity.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 $30 copayment per visit to an out-of-network specialist for Medicare-covered services. You have been asked to pay a $30 copayment for each of the specialist office visits. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows that the provider is a specialist. This means that you have been asked to pay the correct amount based on your Medicare 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 specialist office visits provided from January 7, 2019 to September 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. You say that you are unable to get up and down the stairs, which you need to do for your everyday life. The Plan denied your request. The Plan says this service is not covered by Medicare and therefore not covered by the Plan.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift 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-approve a stair glide.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you did not want the ambulance
transportation because the hospital was only a mile away. You say that your wife took you instead and that you
do not understand why the Plan would not pay for the ambulance response services. You say that you do not
feel like you should be held responsible. The Plan denied your request. The Plan says these services are not a
covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on October 29, 2019. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic surgeon.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on October 7, 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 95937 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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. We find that CPT code 95937 is not supported in the medical record. Specifically, the documentation shows that train of four testing was performed and there is a more appropriate code for these services. 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 services rendered to the enrollee on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided by on December 6, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you thought that follow-up visits
did not have a copayment. The Plan denied your request. The Plan says the claims were processed correctly
and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50
copayment for specialist services.
You had a specialist visit on December 6, 2019. Specialist visits are subject to cost-sharing charges. Therefore,
you are responsible to pay the $50 copayment.
You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls 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 copayment for a specialist visit provided on December 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 29, 2019.
You asked the Plan to pay for the laboratory 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 laboratory services provided on January 29, 2019.