Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings - four radiographic images (D0274), and a teeth cleaning (D1110) provided on September 29, 2020.
You asked the Plan to pay for a periodic oral evaluation, bitewings - four radiographic images, and a teeth cleaning. You say that you would like the plan to pay for these services. The Plan denied your request. The Plan says the services at issue are covered benefits, however the benefit maximum had already been met before this date.
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 plan allows some dental services, up to a $500 annual benefit maximum. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, bitewings - four radiographic images, and a teeth cleaning have not been met. Specifically, the record shows that you had exhausted your dental benefit maximum prior to this date of service. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings - four radiographic images (D0274), and a teeth cleaning (D1110) provided on September 29, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 15 skilled nursing visits.
You asked the Plan to pre-approve the skilled nursing visits. You say that you need these skilled nursing visits to be covered. The Plan denied your request. The Plan says your medical records do not show that you have ongoing nursing needs. The Plan also says that any education and training for you should have already happened with the previous nursing visits you have already had.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 skilled nursing visits. Our reviewer says that the requested skilled nursing visits are not medically necessary. Our physician reviewer found the documentation does not support that you require additional skilled nursing services to provide treatment that is medically necessary. Our reviewer found that you do not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. Our physician reviewer also found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 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 skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the 15 skilled nursing visits.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services performed by a qualified physical therapist in the HH or hospice setting and direct skilled nursing services of a RN in the HH or hospice setting provided from February 7, 2020, to February 27, 2020 by an OON provider.
You asked the Plan to pay for the services performed by a qualified physical therapist and direct skilled nursing services of a RN. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that prior authorization was not 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 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 services performed by a qualified physical therapist in the HH or hospice setting and direct skilled nursing services of a RN in the HH or hospice setting provided from February 7, 2020, to February 27, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a semi-electric hospital bed provided to the enrollee from July 5, 2020, to August 5, 2020.
You asked the Plan to pay for this equipment. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization and did not meet the required criteria for a hospital bed.
Medicare rules say that plans can require enrollees to get prior authorization. Medicare only covers a semi-electric hospital bed when coverage criteria are met. The contract with the Plan says that durable medical equipment requires prior authorization. Based on the records provided, the enrollee did not have prior authorization and did not meet the physical requirements for this type of hospital bed. Therefore, we decided that the Plan does not have to pay for a semi-electric hospital bed provided to the enrollee from July 5, 2020, to August 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two precision attachments (D6950).
You asked the Plan to pre-approve the precision attachments. You say that these services are medically necessary. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental benefit.
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 pre-approve two precision attachments (D6950).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on June 11, 2020.
You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspectedor documented cardiovascular disease.
The Plan must follow Medicare rules. Medicare rules say that a claim that is submitted for Cardiovascular Disease Screening shall be submitted with CPT codes 80061, 82465, 83718 or 84478. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cardiovascular risk assessment testing have not been met. Specifically, this testing is not a Medicare covered benefit. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on June 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has age-related osteoporosis without current pathologic fracture, diagnosis confirmed with bone density testing. The enrollee has failed prior treatment with Evista, calcium and vitamin D. The documentation does not support that the enrollee has tried and failed zoledronic acid. The documentation does not include an indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low back surgery, laminectomy/discectomy, lumbar (63030, 69990)
You asked the Plan to pre-approve the surgical procedure. You say that you are upset because your authorization for outpatient surgery was denied. The Plan denied your request. The Plan says the criteria has not been met as the enrollee has not tried recent non-surgical treatments such as injections or physical therapy.
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 surgical procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records the criteria for surgery not met. There is no documentation of a recent trial and failure of physical 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 surgical procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve low back surgery, laminectomy/discectomy, lumbar (63030, 69990)
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the medical supply that was provided
along with your physical therapy session on October 30, 2020.
You asked the Plan to waive the coinsurance for the medical supply. You say that you were able to
confirm with the hospital that this charge is related to a hot compress that was used during your
physical therapy session. You feel it is unfair to charge you for such an item when it is retained by
the hospital and provided as part of your session. The Plan denied your request. The Plan says that
medical supplies require 20% coinsurance.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing
information. Your contract with the Plan says that enrollees must pay a $35 copayment for each
therapy visit. It does not mention that there will be additional cost-sharing applied to any supplies
provided during these sessions.
The Plan says you must pay 20% coinsurance for the medical supply. The Plan reached this
conclusion by applying the 20% coinsurance for medical supplies as listed in the outpatient
diagnostic tests and therapeutic services and supplies benefit category. However, documentation
shows that this was billed with a physical therapy visit and not in relation to outpatient diagnostic
testing and services or an office visit. The Plan contract does not indicate that supplies used in
conjunction with an outpatient rehabilitation service (physical, occupational or speech language
therapy) will be subject to additional cost-sharing other than the $35 copayment per therapy visit.
Therefore, we decided that the Plan has to waive the coinsurance for the medical supply that was
provided along with your physical therapy session on October 30, 2020.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on October 27, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges because you feel that the distance was too short to warrant a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $240 copayment for ambulance services. You have been asked to pay a $240 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an annual physical examination, annual wellness visit, and annual depression screening provided on November 3, 2020.
You asked the Plan to waive the cost-sharing for annual physical, wellness visit, and depression screening. You say that you had met your maximum out-of-pocket amount. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.
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 40% coinsurance for out-of-network annual physical, wellness visit, and depression screening. The allowed amounts of these services total $266.28, but you have only been asked to pay $77.94 which is less than 40% coinsurance for these services and did not meet the $10,000 combined maximum out-of-pocket amount for 2020.
You have been asked to pay 40% coinsurance for annual physical, wellness visit, and depression screening. Annual physical, wellness visit, and depression screening fall within the "Annual Physical Examination", "Annual Wellness Visit", and "Depression Screening" benefit categories. 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-sharing for an annual physical examination, annual wellness visit, and annual depression screening provided on November 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for vitamin K provided on September 11, 2020.
You asked the Plan to pay for the self-administered drug. You say that your doctor was not able to find vitamin K at any of the local pharmacies. You say that our doctor recommended going to the hospital to to get it. The Plan denied your request. The Plan says the drug that you received is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drug that you received is not covered under Medicare Part B.
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 vitamin K provided on September 11, 2020.
Benefits for the self-administered drug 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided on October 23, 2020.
You asked the Plan to waive the copayment for the lab services. You say that these lab services were part of an annual physical on October 22, 2020. Because of that, you stated that no separate copayment should apply to the lab services. The Plan denied your request. The Plan says this copayment was charged 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 $10 copayment for laboratory tests. The enrollee has been asked to pay a $10 copayment for the lab services. There is no evidence that the lab copayment is waived if the lab service is performed as a result of an annual physical. 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 lab services provided on October 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular overdenture (D5865) and
surgical placements of transosteal implants (D6050) for teeth # 22 and 27.
You asked the Plan to pre-approve the complete mandibular overdenture and transosteal implants. You say that
you feel that these services should be covered. The Plan denied your request. The Plan says these services are
not covered under your benefit package.
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 pre-approve a
complete mandibular overdenture (D5865) and surgical placements of transosteal implants (D6050) for teeth #
22 and 27.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient services and procedures provided on May 8, 2020 and May 9, 2020.
You asked the Plan to pay for the inpatient services and procedures. You say that these procedures were not part of a clinical trial and you are an approved facility. The Plan denied your request. The Plan says that procedures were not billed with a clinical trial number.
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. The Plan has not given specific clinical trial information or why and what number they require. The facility is an approved facility for the procedures performed. Therefore, we decided that the Plan has to pay for the inpatient services and procedures provided on May 8, 2020 and May 9, 2020.
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 pay for the problem focused limited oral evaluation, panoramic x-ray, and extraction provided on June 15, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation, panoramic x-ray, and extraction. You say that you were unaware that this provider did not accept Medicare coverage. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective October 1, 2018, to October 1, 2022. The Plan also says that services performed by a privately contracted provider 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. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 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 when they are received a provider who has opted out of Original Medicare. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, panoramic x-ray, and extraction provided on June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of impacted tooth - partially bony (D7230) and the therapeutic parenteral drug, single administration (D9610).
You asked the Plan to pre-approve the removal of impacted tooth and the therapeutic parenteral drug. You say that you need this service performed because you are on dialysis. The Plan denied your request. The Plan says the requested services are not covered under your supplemental benefit.
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 pre-approve the removal of impacted tooth - partially bony (D7230) and the therapeutic parenteral drug, single administration (D9610).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) angiography of the chest,
abdomen and pelvis (71275 and 74174) provided on June 4, 2020.
You asked the Plan to pay for the CT Angiography. You say that you would like reconsideration because this
service denied as a duplicate in error. The Plan denied your request. The Plan says the records do not support
these services being performed by the rendering provider on the billed date of service.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment
for any item or service, the information submitted by the supplier or provider must corroborate the
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have
been met.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the CT Angiography have not been met. Specifically, the documentation does not support that this
provider rendered these services on the billed date of service. Therefore, we decided that the Plan does not have
to pay for computed tomography (CT) angiography of the chest, abdomen and pelvis (71275 and 74174)
provided on June 4, 2020.