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

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on June 26, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you should not be responsible for the copayment because you say a legitimate service was not provided at the urgent care center. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $30 copayment for all other members of the Northern California Region per visit. The enrollee has been asked to pay a $30 copayment for the urgent care visit. The urgent care visit falls within the all "Urgently needed services" benefit category. The record shows an office visit and vaccinations were provided.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the urgent care visit provided on June 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approveeye prosthesis and follow-up. You say that the enrollee has been your patient for many years and would like to continue care with you.The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider.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 hasnetwork providers available who can provide the items/services at issue in this appeal.No continuity of care issue has been identified in this case.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-approvethe medical services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346) and the topical application of fluoride varnish (D1206) provided on December 19, 2019.
You asked the Plan to pay for the dental services. You say that the dentist advised you needed a different type of cleaning due to the condition of some of your teeth. You also say that the dentist advised that the fluoride was part of the covered procedure. The Plan denied your request. The Plan says the scaling in presence of generalized moderate or severe gingival inflammation and the topical application of fluoride varnish are not listed as covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services that you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346) and the topical application of fluoride varnish (D1206) provided on December 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on
December 10, 2019.
You asked the Plan to waive the copayment for the breast ultrasound. You say that your first mammogram was
not successful. You say you had to go back in for another ultrasound that should be considered a follow-up and
not billed as diagnostic. 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 $100
copayment per day for Medicare-covered diagnostic radiology services.
You have been asked to pay a $100 copayment for the breast ultrasound. The breast ultrasound falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows
this mammogram was diagnostic.
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 breast ultrasound provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the OON services. You say that your primary care physician does not have expertise in your condition.The Plan denied your request. The Plan says the requested clinic recommends the same treatments that are offered within the network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 the requested services. Therefore, we decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvehyperbaric oxygen therapy.You asked the Planto pre-approvethe therapy. You say that this is medically necessary.The Plandenied your request. The Plansayshyperbaric oxygen for non-healing ulcer of the right buttock in a patient without diabetes doesnot meet Medicare criteria for coverage.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 pre-approve the therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found no specific clinical rationale has been provided for the requested therapy. The MRI does not indicate evidence of osteomyelitis. The review has determined that you do not have an indication for hyperbaric oxygen 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 therapy have not been met.Therefore, we decided that the Plandoes not haveto pre-approvehyperbaric oxygen therapy
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
You asked the Plan to pre-approve the dental item. You say that this provider will give you timed payments to get your permanent bridge upper. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the benefit for dentures has been exhausted.
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 and dentures are a covered service, the denture benefit has been exhausted. The record shows that you received a partial upper denture and a lower partial denture on August 18, 2019. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on January 9, 2020.
You asked the Plan to waive the copayment for the endoscopy. You say that you don't have this kind of money to pay. 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 $250 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. You have been asked to pay a $250 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 endoscopy provided on January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve partial upper denture (D5123).
You asked the Plan to pre-approve the partial upper denture. You say that you are requesting reconsideration of the denied service. The Plan denied your request. The Plan says the requested service exceeds the frequency limit.
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. The requested service is allowed once every 5 years. Records show that this service was provided May 17, 2016. 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-approve partial upper denture (D5123).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis LT, RT (L1883) and suspension sleeve LT, RT (L2397) provided November 6, 2019.
You asked the Plan to pay for the orthoses. You say that the records provided should support the necessity of the services in dispute. The Plan denied your request. The Plan says the medical records does not adequately support the medical necessity for the item.
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 the orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found none of the submitted information notes any complaint or evaluation of the enrollee's knees. There is no documented history, recent injury or surgery, associated symptoms, review of systems or physical examination, including weakness and/or deformity related to the enrollee's knees. There is no evidence of a diagnostic evaluation (i.e. x-rays) or prescription therapy provision/response (i.e. prescription medications, injections, PT/OT) of the enrollee's knees. Therefore, the documentation does not support the medical necessity or reasonableness of the provided service.
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 orthoses have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis LT, RT (L1883) and suspension sleeve LT, RT (L2397) provided November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the sleep apnea appliance to be provided by an out of network provider,
You asked the Plan to pre-approve the sleep apnea appliance from an out-of-network provider. You say that the Plan does not have a provider/DME supplier in the enrollee's area. The Plan denied your request. The Plan says you have been given a referral to an in-network provider for the sleep apnea appliance.
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 the sleep apnea appliance to be provided by an out of network provider,
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that you have been unable to have your needed surgery due to infections. You say that you need the requested shoe inserts to help you walk. You say that the new virus is forcing elderly people to stay home and so you need help paying for the necessary inserts so that you can walk.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on July 26, 2019 and September 9, 2019.You asked the Plan to waive the copayment forlaboratory services. You say that this is a free-standinglab. You say that the lab should be fully covered.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 $70 copayment for lab services at an in-network outpatient hospital. You have been asked to pay a total of $135.96 for the laboratory services. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the laboratory services were billed by the hospital. 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 forlaboratory services provided on July 26, 2019 and September 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 15, 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. The rules state that DMEPOS is covered only when the patient's medical record contains 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. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a drug test to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a drug test. You say that you would like approval for these services. The Plan denied your request. The Plan says 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 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. Please contact the Plan for a list of in-network providers available. 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 drug test to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve panniculectomy surgery.
You asked the Plan to pre-approve panniculectomy. You say that you had a hernia and want the excess skin removed that was caused by the hernia. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that panniculectomy is only covered for enrollees who meet certain specific criteria. 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 panniculectomy. Our reviewer says that you do not meet the Medicare criteria for the requested procedure. Our physician reviewer found there is insufficient documentation of your chronic rashes, including the time period of symptoms or the time period of treatment. In addition, as the specifics of over-the-counter medications has not been documented, it is unclear if you have been receiving appropriate medical therapy. Finally, it does not appear that the pannus hangs below the level of the pubis. The examination detail does not describe the degree of pannus present. Therefore, panniculectomy for you does not satisfy Medicare's medical necessity criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of panniculectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve panniculectomy surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the electric lift recliner warranty and sales tax.
You asked the Plan to reimburse you for the recliner warranty and sales tax. You say that the lift chair is medically necessary. The Plan denied your request. The Plan says they will reimburse you the Medicare fee schedule for the seat lift mechanism portion of the recliner but they do not reimburse warranties or sales tax separately.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. Medicare does not cover the upholstered portion of a seat lift chair. We looked at the file and Medicare rules. The Plan is reimbursing you for the seat lift mechanism portion, at the Medicare payment guideline for your state, minus your 20% cost share. Medicare does not pay for warranties or sales tax separately. Based on this information, we decided that Medicare rules for coverage of the recliner warranty and sales tax have not been met. Therefore, we decided that the Plan does not have to reimburse you for the electric lift recliner warranty and sales tax for the purchase from the facility on May 29, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs are custodial in nature.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart with evaluation of coronary calcium.
You asked the Plan to pre-approve these services. You say that your doctor said you needed the procedure. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT 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 submitted records show that you have documented chest discomfort and reduced blood flow (ischemia) on a recent good quality nuclear stress test. In this circumstance, a CT scan with coronary calcium scoring would not effect the treatment plan. Since the results of the CT scan would not change the treatment plan, the services are not reasonable or medically necessary. 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 computed tomography (CT) scan of the heart with evaluation of coronary calcium.