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

We decided that the Plan does not have to pre-approve a referral to an out-of-network pain management specialist.You asked the Plan to pre-approve these services. You say that you are seeing this provider for medication refills.The Plan denied your request. The Plan says the servicesare available from network providers.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 pain management specialist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings.You asked the Plan to pre-approve the compression stockings. You say that the enrollee requires the stockings to aid in treatment for syncope.The Plan denied your request. The Plan says gradient compression stockings are non-covered when there is no qualifying wound.The Plan must follow Medicare rules. Medicare rules say that compression stockings 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and sleeve (L2397) provided December 26, 2019.You asked the Plan to pay for the orthoses. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says the services are not supported in the medical records received.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is no objective documentation of joint laxity.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met.Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and sleeve (L2397) provided December 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe oral exam (D0120) cleaning (D1110) bitewing x-rays (D0274) and intraoral-periapcal x-ray (D0220) provided December 2, 2019.You asked the Plan to pay forthe dental services. You say that you were not notified that the provider had opted out. The services from previous visits were paid for and you were not aware of any changes.The Plan denied your request. The Plan says this provider is provider not eligible to participate in Medicare.The Plan must follow Medicare rules. 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.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by . This provider has opted out of the Medicare program. The file shows that  entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay forthe oral exam (D0120) cleaning (D1110) bitewing x-rays (D0274) and intraoral-periapcal x-ray (D0220) provided December 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the rituximab injection provided on
January 25, 2019.
You asked the Plan to waive the coinsurance for the rituximab injection. You say that this is too much money
for an injection. You say that you cannot afford the cost. 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 chemotherapy prescription drugs and non-chemotherapy prescription drugs.
You have been asked to pay $1,623.46, which is 20% of the allowed amount for the rituximab injection. The
allowed amount is $8,117.28 (20% x $8,117.28 = $1,623.46). The rituximab 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 rituximab injection provided on January 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the enrolleefor hearing aids provided on September 21, 2019You asked the Plan to reimburse the enrolleefor the hearing aids. You say that due to the enrollee's age and medical conditions you were able to eliminate the need for multiple appointments to test, fit and order hearing aids. You say the hearing aids purchased were affordable work well. The Plan denied your request. The Plan says this provider is not eligible to participate in Medicare.The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. A supplier means a physician or other practitioner, or an entity other than a provider that furnishes health care services under Medicare.We looked at the file and the Medicare rules. The hearing aids were provided by an entity other than a provider that furnishes health care services under Medicare.The hearing aid supplier is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to reimburse the enrolleefor hearing aids providedon September 21, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IBRANCE
You asked the Plan to pre-approve IBRANCE. You say that you want the enrollee to start treatment on this drug. The Plan denied your request. The Plan says this is not a Part B covered drug.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. This drug does not have a non-self-administered equivalent and therefore does not meet exception criteria. Therefore, we decided that the Plan does not have to pre-approve IBRANCE.
Benefits for IBRANCE 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete upper denture (D5110) and an immediatelower denture (D5140).You asked the Plan to pre-approvethe dentures. You say that you are requesting a reconsideration of the Plan's denialas you have not used your benefits for this year or the previous year.The Plan denied your request. The Plan says that youhave exhausted the allowable benefit for these services.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the case file and Plan's rules. Based on this information, we decided that the Plan's rules for coverage of these serviceshave not been met.Specifically, your requestexceedsthe allowable benefit limitation as you have previously received acompleteset of dentures on November 21, 2019. The benefit allows for one complete set of dentures every five years. Therefore, we decided that the Plan does not have to pre-approvea complete upper denture (D5110) and an immediate lower denture (D5140).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 22, 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 referring provider 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 October 22, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis 0.05% eye emulsion for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is intended for patient self-administration.
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 pre-approve Restasis 0.05% eye emulsion for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered to you on December 9, 2019.You asked the Plan to waive the copayment for these services. You say that you believe a $25 copayment for physician's services should apply.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). Your contract with the Plan clearly says that you must pay a $275 copayment for Medicare-covered outpatient services at hospital facilities. Review of the file shows that you received services at an outpatient hospital facility on December 9, 2019. You have been asked to pay a $275 copayment for these services. These services fall within the Medicare-covered outpatient services at hospital facilities 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 forthe outpatient hospital services rendered to you on December 9, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99283) and drainage (11060) provided on April 24, 2018.
You asked the Plan to pay for the emergency department visit and drainage. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the provider did not submit the claim within the allotted timeframe of 12 months.
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 emergency department visit and drainage was not filed until October 11, 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 for the emergency department visit (99283) and drainage (11060) provided on April 24, 2018.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received April 16, 2019, and June 25, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted
out of Medicare.
The Plan must follow Medicare rules. 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.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider that
has opted out of the Medicare program. The file shows that this provider entered into a private contract with
you regarding payment. Therefore, we decided that the Plan does not have to pay for the services you received
April 16, 2019, and June 25, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay forthe catheters provided to the enrollee on October 1, 2019.You asked the Plan to pay forthe catheters. The Plan denied your request. The Plan says that that the billed supply code and units cannot be verified.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. We looked at the file and Medicare rules.The file contains a valid order and itemized delivery ticket showing that the billed amount of supplies were provided. Based on this information, we decided that Medicare rules for coverage of the cathetershave been met.Therefore, we decided that the Plan has to pay forthe catheters provided to the enrollee on October 1, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller and harness for the enrollee.
You asked the Plan to pre-approve an expandable controller and harness. The Plan denied your request. The Plan says that an expandable controller and harness are not allowed in this situation unless an interface is used.
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 an expandable controller and harness. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. The documentation does not reveal that the patient requires a proportional input device, an attendant control, other electronic devices such as augmentative speech device, a separate display, a non-proportional input device such as sip and puff, or the need to control three or more power seating actuators through the drive control. The patient's strength is sufficient to control any power options with their separate switches which would be included with the approval of power options. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of an expandable controller and harness. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller and harness have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller and harness for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy (PT) services rendered to you on November 5, 2019.
You asked the Plan to waive the copayment for these services. You say that the approval letter does not say there is a copayment. 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). Your contract with the Plan clearly says that you must pay a $40 copayment for each in-network Medicare-covered therapy visit.
Review of the file shows that you received PT services on November 5, 2019. You have been asked to pay a $40 copayment for these services. These services fall within the in-network Medicare-covered therapy visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the physical therapy (PT) services rendered to you on November 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordiagnostic digital breast tomosynthesis (CPT 77061) provided to the enrollee on December 31, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis code is not valid for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 77061 is "Diagnostic digital breast tomosynthesis; unilateral."We find that CPT code 77061 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordiagnostic digital breast tomosynthesis (CPT 77061) provided to the enrollee on December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis
(D1110) provided on December 17, 2019.
You asked the Plan to pay for the dental services. You say that it appears you already received 2 cleanings and
oral exams. You say that this was your error. The Plan denied your request. The Plan says the frequency limit
of 2 oral exams and 2 cleanings per plan year have been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage and the oral exam and cleaning are
listed as covered services, the frequency limits have been exceeded. The record shows that the Plan paid for
these services that you received on January 15, 2019 and July 16, 2019. Therefore, we decided that the Plan
does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on December
17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ankle foot orthosis (L1971) provided on December 18, 2019.
You asked the Plan to pay for the orthosis. You say that the records provided should support the necessity of the services in dispute. The Plan denied your request. The Plan says no medical records were provided to corroborate the services and confirm Medicare coverage has been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for ankle foot orthosis (L1971) provided on December 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for keratoplasty provided on October 17, 2019.You asked the Plan to waive the copayment for keratoplasty. You say that you had to have the procedure redone and feel that you should not have to pay the 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 $200 copayment for outpatient surgery services. You have been asked to pay a $200 copayment for keratoplasty. Keratoplasty falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for keratoplasty provided on October 17, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on April 23, 2019.Youasked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on April 23, 2019.