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

We decided that the Plan does not have to pay for the Cravit tablet, Ropect Rolar capsule, Lorsedin Aller tablet, Effervescent tablet, and Norgesic tablet provided on January 11, 2020.
You asked the Plan to pay for the Cravit tablet, Ropect Rolar capsule, Lorsedin Aller tablet, Effervescent tablet, and Norgesic tablet. You say that you paid the billed amount up front and would like to be reimbursed. The Plan denied your request. The Plan says the services were performed outside the service area and did not meet the emergent/urgent services criteria to prevent deterioration of the health due to unforeseen illnesses.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Cravit tablet, Ropect Rolar capsule, Lorsedin Aller tablet, Effervescent tablet, and Norgesic tablet provided on January 11, 2020.
Benefits for the Cravit tablet, Ropect Rolar capsule, Lorsedin Aller tablet, Effervescent tablet, and Norgesic tablet may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit provided by an out-of-network provider on February 15, 2021.

You asked the Plan to pay for the nursing facility visit. You say that you were informed a referral could not be provided because the patient had not been seen for a long time. You say that the in-network nursing facility granted privileges to provide necessary medical services and the claim should be considered for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was not approved in advance.

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 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 nursing facility visit provided by an out-of-network provider on February 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You have likely reached a new level of function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care. 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the family therapy visits (90847) provided January 11, 2021 to January 19, 2021.

You asked the Plan to pay for the family therapy. You say that you tried to find services with other provider's and they are only able to help those who were in extreme mental distress. You have to pay out of pocket for all expenses for services rendered at this time. The Plan denied your request. The Plan says the provider is not in network and is not a Medicare contracted provider. Enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the family therapy visits (90847) provided January 11, 2021 to January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and extraction (D7140) provided on January 26, 2021 by an OON provider.

You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and extraction. You say that you requested a list of in-network providers, but did not receive the list by this date of service. You also say that you need help paying this bill. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that your plan has OON benefits, but your out of pocket costs may be higher.

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, you are responsible for the $100 deductible for the extraction, plus the difference between the billed amount and allowed amount for dental services received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and extraction (D7140) provided on January 26, 2021 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus Gene Panel provided on January 7, 2020.
You asked the Plan to pay for the Tempus Gene Panel. You say that you would like reconsideration because the Tempus Gene Panel will play an important role in establishing specific somatic tumor and germline mutations which will guide appropriate medical management of the member. The Plan denied your request. The Plan says this testing was not reported per Medicare guidelines.
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 Tempus Gene Panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found per the National Comprehensive Cancer Network, there is no indication for molecular testing to guide treatment. 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 Tempus Gene Panel have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus Gene Panel provided on January 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond July 3, 2021.

You asked the Plan to pre-approve the continued SNF care. You say that you believe that the enrollee would benefit from continued daily skilled care. The Plan denied your request. The Plan says the enrollee no longer requires or will benefit from daily skilled services.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care for a femur fracture and underwent open reduction and internal fixation (ORIF) to surgically treat the fracture. She was discharged to the SNF on 6/17/2021. As of July 1, 2021, she remains non-weight bearing in the left leg. Occupational therapy has focused on positioning and dynamic sitting to increase participation in daily living activities. 

The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee has reached a plateau in function given her weight bearing limitation. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care. 

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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond July 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig.

You asked the Plan to pre-approve a wig. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not primarily medical in nature. Therefore, coverage criteria have not been met.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. 

In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and two additional intraoral periapical x-rays provided on February 10, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation and intraoral periapical x-rays. You say that this provider was listed in the Plan's provider directory as in-network. You also say that the dentist office advised you that they were in-network. The Plan denied your request. The Plan says these services 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 are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
problem focused limited oral evaluation, first intraoral periapical x-ray, and two additional intraoral periapical
x-rays provided on February 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services provided on November 4, 2020.
You asked the Plan to pay for the critical care services. You say that the record supports the services billed. The Plan denied your request. The Plan says this cannot be paid since time spent is not documented.
The Plan must follow Medicare rules. Medicare rules say that as critical care services are time-based, time spent providing care must be documented in the progress note. We reviewed the progress note for this date of service. There is no documentation of the time spent providing these services. Based on this information, we find that the 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 provided on November 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the computed tomography (CT) scan and radiation therapy services provided from January 4, 2021, to January 29, 2021.
You asked the Plan to waive the cost shares for the services provided. You say that you were not advised your expenses would increase so much. The Plan denied your request.
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 $175 copay for advanced imaging services and a 20% coinsurance for therapeutic radiation services.
You have been asked to pay a $143.64 copay for each CT scan. Because the amount is less than the $175 copay, you were charged the lesser amount. You were also asked to pay a 20% coinsurance for the radiation services. The services fall within the outpatient diagnostic tests 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 shares for the computed tomography (CT) scan and radiation therapy services provided from January 4, 2021, to January 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the specimens are sent to the facility by the enrollee's primary physicians. The Plan denied your request. The Plan says the services were not authorized.
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 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 the lab services provided on July 14, 2020 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 periodontal maintenance provided on December 23, 2020 by an OON provider.
You asked the Plan to pay for the periodontal maintenance. You say that in early 2020 this provider was in-network. You also say that after your cleaning on December 23, 2020, you found out this provider was no longer in-network. The Plan denied your request. The Plan says you received this service from a non-participating provider. The Plan also says that services done by an OON dentist 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, you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance provided on December 23, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the specialist visit provided on December 22, 2020.
You asked the Plan to waive the copay for the specialist services. You say that you received routine blood work, not an office visit. The Plan denied your request. The Plan says the claim processed 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 $35 copay for physician specialist services. The medical records provided show that you received a follow-up visit with a pulmonology specialist. You have been asked to pay a $35 copay for the specialist services. The services fall within the physician 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 copay for the specialist visit provided on December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe destruction of prostate gland using ultrasound guidance (55873).You asked the Plan to pre-approvethe destruction of prostate gland using ultrasound guidance. You say that this request is medically necessary.The Plan denied your request. The Plan says there is no evidence of recurrent prostate cancer or a trial of radiation treatment.The Plan follows Medicare rules. Medicare rules say that salvage cryosurgery of the prostate is subject to the criteria listed in the Medicare rules section.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 destruction of prostate gland using ultrasound guidance. Our reviewer says that the request is not medically reasonable and necessary. Our physician reviewer found the record indicates that you are a 73-year-oldman who was recently diagnosed with prostate cancer. In this case, the requested treatment is not salvage therapy as necessitated by the NCD. The elements of the coverage criteria are not satisfied inthis case.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 destruction of prostate gland using ultrasound guidance have not been met.Therefore, we decided that the Plan does not have to pre-approvethe destruction of prostate gland using ultrasound guidance (55873).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for renal dialysis services you received from January 1, 2021, to January 18, 2021.
You asked the Plan to waive the coinsurance for the dialysis services. You say that this cost sharing is too high. The Plan denied your request. The Plan says you were charged this coinsurance 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 renal dialysis services. You have been asked to pay 20% coinsurance for the dialysis services. 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 renal dialysis services you received from January 1, 2021, to January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on January 22, 2021.
You asked the Plan to pay for the dental service. You say that you were advised when you signed up for the plan that you would have $2,000 for dental services. You say that you do not have the money to take care of your teeth. You say that you will not have coverage. You also say that your tooth is still hurting, and you are tired of the pain. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services performed out of network 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 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on January 22, 2021.
Your complaint about being misinformed by a plan representative 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Factor II and Factor V Leiden testing provided from January 28, 2021, to February 3, 2021.

You asked the Plan to pay for Factor II and Factor V genetic testing. You say that your doctor referred you for these services.The Plan denied your request. The Plan says the denial of payment for these tests is correct, because these tests were not provided for a covered diagnosis. The Plan also says that they have approved payment for all other services provided in these claims, so this denial is only for the Factor II and Factor V gene tests.

The Plan must follow Medicare rules. Medicare rules say that Factor II and Factor V gene tests are only covered for certain diagnoses, which do not include diagnosis code I47.1. 

We looked at the file and Medicare rules. These tests were not provided for a covered diagnosis. Based on this information, we decided that Medicare rules for coverage of Factor II and Factor V genetic testing have not been met.Therefore, we decided that the Plan does not have to pay for Factor II and Factor V Leiden testing provided from January 28, 2021, to February 3, 2021.