Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 800 Contour Next test strips for a 90 day period (A4253).
You asked the Plan to pre-approve 800 Contour Next test strips for a 90 day period. You say that the requested items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that the quantity of test strips (code A4253) and lancets (code A4259) that are covered depends on the usual medical needs of the beneficiary and whether or not the beneficiary is being treated with insulin, regardless of their diagnostic classification as having Type 1 or Type 2 diabetes mellitus. 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 800 Contour Next test strips for a 90 day period. Our reviewer says that the requested amount is not medically necessary. Our physician reviewer found you are noted to be a type I diabetic, who uses an insulin pump and a Continuous Glucose Monitor (CGM). A request has been made for blood glucose testing strips at a quantity that corresponds to testing 8.8times/day. It is unclear why, if you have a CGM, you need to manually test your blood glucose 8.8times/day. The CGM itself should not require the use of testing strips. An occasional manual check to confirm the CGM is reasonable, but does not need to be done 8.8times/day. At present, the documentation does not support the medical necessity or reasonableness of the large volume of blood glucose testing strips requested. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 800 Contour Next test strips for a 90 day period have not been met. Therefore, we decided that the Plan does not have to pre-approve 800 Contour Next test strips for a 90 day period (A4253).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).
You asked the Plan to pre-approve the dental item. You say that you had a bad experience with your previous
provider and do not wish to go back to them. You say that your previous provider should refund the Plan for
the denture you received so you can get an upper denture from a different dentist. You say that you were not
satisfied with the way that you were treated. You also say that you are entitled to reject the service and insist on
a refund. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also
says the denture benefit 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, the benefit limit for dentures of once
every 5 years has been exhausted. The record shows that you last received a complete upper denture on
November 9, 2017. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture
(D5110).
Your complaint about being treated poorly by your previous dental provider 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: 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 continuous glucose monitor. You say that you need a continuous glucose monitor. The Plan denied your request. The Plan says you are not on multiple doses of insulin a day or use 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 testing four or more times a day or insulin treated three or more times a day. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor 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 physician services provided on October 22, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for physician services. You say that the facility failed to obtain the necessary
authorization for this patient. You say that you were referred by the facility. The Plan denied your request. The
Plan says the referring provider is out-of-network. The Plan says that 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 physician services provided on October 22, 2019
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetoilet grab bars.You asked the Plan to pre-approvetoilet grab bars. You say that the enrollee needs hand rails for safe toileting.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar 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-approvetoilet grab bars.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the service is available within the primary 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 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 provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forout of area services provided on December 28, 2017.You asked the Plan to pay forthe out of area services. You say that you would like reconsideration because you submitted the claims on time to the member's most recent plan.The Plan denied your request. The Plan says you must submit your claim within 12 months of the date the service or item was received.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the out of area services was not filed until October 25, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forout of area services provided on December 28, 2017.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 4) and bitewing x-rays (D0274) provided from November 21, 2019 to December 3, 2019.
You asked the Plan to pay for the periodontal scaling and root planing. You say that this service should be covered under your plan benefits. The Plan denied your request. The Plan says periodontal scaling and root planing is not a covered service.
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, periodontal scaling and root planing is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 4) and bitewing x-rays (D0274) provided from November 21, 2019 to December 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 30, 2019.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you went to one provider for a cleaning and x-rays, who told you that you had three cavities. You also say that you went to a second dentist and had your teeth cleaned and x-rays taken, and were told you did not have any cavities. The Plan denied your request. The Plan says your dental benefits have 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, 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 comprehensive oral evaluation (D0150) provided on December 30, 2019.
Your complaint about being given false information by the first provider 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is not bed bound, does not require frequent positioning, and does not have congestive heart failure or COPD that requires the enrollee to be up at 30 degrees while in bed.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 bed. Our reviewer says that the requested bed is not medically reasonable or necessary. Our physician reviewer found there is no deformity that would indicate a need for positioning that would require a special bed. There is no history of pressure ulcers or inability to perform effective pressure reliefs. The enrollee has normal strength and has active and passive range of motion in all extremities. There is no identified significant upper extremity impairment. There would be no need for a modified bed. The requested hospital bed is not 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 the bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the infliximab injection provided on January 2, 2020.
You asked the Plan to waive the coinsurance for the infliximab injection. You say that you previously had no cost for the injection. You say that the cost should be clarified. 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 prescription drugs. You have been asked to pay $573.50 for the infliximab injection.
The infliximab 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 infliximab injection provided on January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the assay of creatinine rendered on September 4, 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 assay of creatinine rendered on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on November 11, 2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 a domiciliary, rest home visit provided on November 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on August 1, 2019.
You asked the Plan to pay for drug test. You say that you are submitted the laboratory requisition that includes a valid physician order. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this documentation submitted does not include a valid physician order, laboratory requisition, or medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Hepatitis A and B vaccine you received on December 4, 2019.
You asked the Plan to pay for the vaccine. You say that this vaccine is necessary. The Plan denied your request. The Plan says this is not covered under Part B.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the Hepatitis A and B vaccine you received on December 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered to the enrollee on January 22, 2020.
You asked the Plan to waive the copayment for these services. You say that the enrollee did not have a choice in the services. The Plan denied your request. The Plan says the copayment was 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $50 copayment for Medicare-covered outpatient lab services at an outpatient hospital.
Review of the file shows that the enrollee received laboratory services at an outpatient hospital facility on January 22, 2020. The enrollee has been asked to pay a $50 copayment for these services. These services fall within the Medicare-covered outpatient lab services at an outpatient hospital benefit category. 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 laboratory services rendered to the enrollee on January 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses you received on October 22, 2019.
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says the benefit limit has been reached.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these eyeglass frames up to $70. We looked at the file and the Plan's rules. The records show that the eyeglass frames you received were billed at $114. The plan paid $70 toward the frames. This means that you are responsible for the $44 balance for the frames. Based on this information, we decided that the Plan's rules for coverage of additional payment for the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses you received on October 22, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for initial nursing facility care provided on September 19, 2019.
You asked the Plan to pay for the initial nursing facility care. 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 initial nursing facility care provided on September 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the frames and glasses provided on December 3, 2019.
You asked the Plan to provide additional payment for the frames and glasses. The Plan denied your request. The Plan says that the claim processed correctly.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to a $100 allowance for frames and lens. We looked at the file and the Plan's rules. The file shows that the plan has approved the maximum yearly benefit of $100 for the requested services. There is no provision in the contract which would require the plan to approve more than this amount.. Therefore, we decided that the Plan does not have to provide additional payment for the frames and glasses provided on December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 7, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because you were there to receive a surgical procedure not as a new patient. 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 $35 copayment for each specialist visit, including outpatient clinic visits. The medical records show that you received specialist services on January 7, 2020. Therefore, you are responsible to pay the $35 copayment. You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the outpatient hospitals 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 copayment for a specialist visit provided on January 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder x-ray rendered on November 20, 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 73020 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 73020 and 73030. Code 73020 is a column II code with a modifier indicator of 1 when billed with column I code 73030. Code 73020 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the shoulder x-ray rendered on November 20, 2019.