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

We decided that the Plan does not have to pre-approve varicose vein treatment to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested services can be provided by a 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 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 varicose vein treatment to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99232) rendered by out of network (OON) provider on July 31, 2019.You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment as the physician provided medically necessary services to the enrollee in good faith.The Plan denied your request. The Plan says the services were provided by an out of network provider, without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the 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 subsequent hospital care (99232) rendered by the out of network (OON) provider on July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for counseling services provided on December 4, 2019 by an out of network (OON) provider.You asked the Plan to pay for counseling services. You say that you were unaware that authorization was required.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 counseling services provided on December 4, 2019 by an out of network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe CPAP and oxygen services to be provided by an out of network provider.You asked the Plan to pre-approvethe CPAP and oxygen services from an out-of-network supplier. You say that you want to continue to receive the CPAP and oxygen services from the out-of-network supplier.The Plan denied your request. The Plan says the CPAP and oxygen services can be provided 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 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-approvethe CPAP and oxygen services to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Acupuncture services.You asked the Plan to pre-approve Acupuncture services. You say that you have neck pain and you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says you do not have a covered indication for Acupuncture.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90 period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, you are requesting Acupuncture for your neck pain. This is not a covered indication for Acupuncture under Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approve Acupuncture services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 22 surgical extractions and anesthesia provided on August 21, 2019.
You asked the Plan to pay for the dental services. You say that it was necessary for the enrollee to receive these services in a hospital setting. The Plan denied your request. The Plan says the services that the enrollee received were dental in nature. The Plan also says that the services are not covered under the enrollee's medical benefit.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the 22 surgical extractions and anesthesia provided on August 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549, A6530.
You asked the Plan to pre-approve the compression stockings. You say that the enrollee requires the stockings for pain. The Plan denied your request. The Plan says gradient compression stockings A6549, A6530 are non-covered when there is no qualifying wound.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549, A6530 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549, A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe shower chair provided on November 4, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe shower chair. You say that  The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan cannot pay a provider who is not eligible to participate in Medicare.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 carefrom out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The Plan must follow Medicare rules.Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.Medicare rules say to receive payment for covered Medicare items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be enrolled in the Medicare program. While a shower chair 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 pay forthe shower chair provided on November 4, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on October 24, 2019.
You asked the Plan to waive the coinsurance for the denosumab injection. You submitted your bills for review. You say that you only received one injection. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B covered drugs at an in-network primary care provider's office. You have been asked to pay $219.84, which is 20% of the allowed amount for the denosumab injection. The allowed amount is $1,099.20 (20% x $1,099.20 = $219.84). The denosumab 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 coinsurance for the denosumab injection provided on October 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Computed Tomography (CT) of the Abdomen and Pelvis (74177) provided December 12, 2019.You asked the Plan to waive the copayment for the CT scan. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct cost-sharing was 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 $150 copayment for Diagnostic Radiology. You have been asked to pay a $150 copayment for the CT scan. The CT scan falls within the Diagnostic Radiology 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 Computed Tomography (CT) of the Abdomen and Pelvis (74177) provided December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 12, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 services at issue in this appeal. 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 medical services provided to the enrollee by an out-of-network provider on November 12, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 2, 2019 to October 8, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from networkproviders. 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 forthe medical services provided on October 2, 2019 to October 8, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory work provided on December 13, 2019.You asked the Plan to waive the copayment forthe laboratory work. You say that the Prostate Cancer Screening Exam is a preventive screening and should have a $0 copayment.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 $15 copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility). You have been asked to pay a $15 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you also had other laboratorywork done for an existing medical condition.This means that you have been asked to pay the correct amount based onyour 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 forthe laboratory work provided on December 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis provided by Connection CareGroup on December 4, 2019.You asked the Plan to pay for the wrist hand orthosis (L3916). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says the enrollee had the same orthosis still under reasonable useful lifetime.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, itis not considered reasonable and necessary.The file shows that enrollee had a wrist hand orthosis, provided by a different provider on February 20, 2018, at the time the wrist hand orthosis (L3916) was received. The wrist hand orthosis provided by a different provider on February 20, 2018 serves the same purpose as the wrist hand orthosis (L3916)provided by you. This orthosis is still within the 5-year RUL and the documentation submitted does not show that the enrollee's orthosisis irreparably worn, irreparably damaged, or that the enrolleehad a change in medical condition to warrant the orthosisat issue. Based on the records provided, there is no indication that the orthoses provided met Medicare coverage criteria for replacement at the time of issue. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis provided by Connection CareGroup on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 12, 2019 by an out of network (OON) provider.
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 rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 medical services provided on November 12, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous positive airway pressure (CPAP) device (E0601), tubing with integrated heating element for use with positive airway pressure device (A4604), and humidifier, heated, used with positive airway pressure device (E0562).
You asked the Plan to pre-approve a CPAP device, tubing with integrated heating element, and humidifier. You say that your current equipment is nine years old and needs to be replaced. The Plan denied your request. The Plan says that the documentation provided does not show the equipment is over five years old or is unable to be repaired. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan did not provide medical records. Without this documentation, the Plan denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pre-approve a continuous positive airway pressure (CPAP) device (E0601), tubing with integrated heating element for use with positive airway pressure device (A4604), and humidifier, heated, used with positive airway pressure device (E0562).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental consultation (D9310) and surgical extraction of tooth #17 (D7210) by an oral surgeon.
You asked the Plan to pre-approve the dental services. You say that you are requesting reconsideration because you have been in severe pain for too many months now. The Plan denied your request. The Plan says the requested service is not covered when rendered by an oral surgeon.
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 health plan contract specifically says dental services are only covered when rendered by a participating general dentist. 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 a dental consultation (D9310) and surgical extraction of tooth #17 (D7210) by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring system.
You asked the Plan to pre-approve a CGM. You say that your doctor prescribed a continuous glucose meter because you are finger stick testing four to five times a day. The Plan denied your request. The Plan says there is no Medicare or Plan benefit for a person who is not on multiple doses of insulin a day or not using an insulin pump.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. The record shows you are not insulin treated. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on November 14, 2019.
You asked the Plan to pay for the services. 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 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. 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 medical services provided to the enrollee by an out-of-network provider
on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided on October 22, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for dermatology services. You say that you were told that this provider took your
insurance. You say that the visit was only about 15 minutes. 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 dermatology services provided on October 22,
2019 by an out of network (OON) provider.