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

We decided that the Plan does not have to pay for the dental services provided on July 18, 2019 to August 1, 2019, while outside of the United States.You asked the Plan to pay for the dental services. You say that while outside of the US you had pain to the extent that you lost consciousness. You were admitted to the hospital twice as a result. The insurance was called and authorized the hospital admission.The Plan denied your request. The Plan says dental services provided while outside of the United States is not covered. Medicare says that plans must pay for emergency and urgently needed services. The contract with the Plan says while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.These dental services were non-emergent/urgent services provided while outside of the United States. 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 dental services provided on July 18, 2019 to August 1, 2019, while outside of the United States.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omnitrope 5mg/1.5ml crtg (J2941).You asked the Plan to pre-approve Omnitrope 5mg/1.5ml crtg. You say that the requested medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Omnitrope 5mg/1.5ml crtg. Our reviewer says that the medication is not medically necessary. Our physician reviewer found review of Medicare compendia does not support the use of Omnitrope for the noted medical diagnoses. Without the support of the documentation, medical necessity cannot be approved.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Omnitrope 5mg/1.5ml crtg have not been met.Therefore, we decided that the Plan does not have to pre-approve Omnitrope 5mg/1.5ml crtg (J2941).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950)
on tooth #29 and prefabricated post and core in addition to crown (D2954) on tooth #29 provided on January
16, 2020.
You asked the Plan to pay for the core buildup and prefabricated post and core. The Plan denied your request.
The Plan says these services exceed the benefit allowance.
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, one core buildup, including any pins
when required (D2950), post and core in addition to crown (D2952), or prefabricated post and core in addition
to crown (D2954) is covered per 60 months per tooth. The records show that you received a core buildup,
including any pins when required (D2950) on tooth #29 on July 18, 2019 and your benefit has been exhausted.
Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required
(D2950) on tooth #29 and prefabricated post and core in addition to crown (D2954) on tooth #29 provided on
January 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from May 17,
2019 to May 22, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says this was not billed with the correct bill type.
The Plan must follow Medicare rules. Medicare rules say that home health services must be billed correctly.
The billed claim is for a non-participating home health provider, and the appropriate home health date Bill of
Type was not billed correctly. Based on this information, we decided that Medicare rules for coverage of the
services have not been met. Therefore, we decided that the Plan does not have to pay for home health services
provided to the enrollee from May 17, 2019 to May 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Shingrix or shingles vaccine provided on September 24, 2019.
You asked the Plan to pay for this vaccine under Medicare Part B. You say that this vaccine should be covered by the Plan. The Plan denied your request. The Plan says this vaccine is not covered under Medicare Part B and should be submitted to your Medicare Part D carrier.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide this vaccine under Medicare Part B. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to this vaccine under Medicare Part B. This vaccine was preventative in nature. Therefore, we decided that the Plan does not have to pay for the Shingrix or shingles vaccine provided on September 24, 2019.
Benefits for this vaccine under Medicare Part B 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0848). You asked the Plan to pre-approve the power wheelchair. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the Medicare rules have not been met. 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 power wheelchair. Our physician reviewer found in this case, the patient is not noted to have inability to utilize a lesser device (lightweight manual wheelchair, standard manual wheelchair, or use of a walker). Therefore, this request is not medically necessary for a PMD.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 power wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approve power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0848).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on January 14, 2020.
You asked the Plan to pay for the orthoses. 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. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Continuous Glucose Monitor (CGM) (K0553).
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied
your request. The Plan says coverage criteria has not been met.
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 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 CGM. Our reviewer says that the
Continuous Glucose Monitor is not medically necessary. Our physician reviewer found the enrollee does not
use insulin to treat their diabetes. Therefore, the enrollee cannot be using the results of blood glucose testing to
self-adjust, self-administered insulin doses, multiple times per day. As such, the use of a CGM 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 CGM have not been met. Therefore, we decided that the Plan does not have
to pre-approve a Continuous Glucose Monitor (CGM) (K0553).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization inpatient care provided November 12 to November 16, 2019.You asked the Plan to pay for the inpatient services. You say that the services were medically necessary.The Plan denied your request. The Plan says the enrollee should have been transferred to an in-network facility for post-stabilization treatment. The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient services. Our reviewer says that rules for coverage were not met. Our physician reviewer found the record shows that the enrollee was stable for transfer to a plan facility after initial treatment in the emergency department.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 inpatient services have not been met.Therefore, we decided that the Plan does not have to pay for post-stabilization inpatient care provided November 12 to November 16, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on January 8, 2020 at this time.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says it is noted the Waiver of Liability received on March 19, 2020 shows a date range from January 08, 2020 through February 26, 2020.  After additional claim research, the claim system is showing date of service February 26, 2020 was processed and denied as "Hospice Member-Bill Hospice/ FFS Carrier".  A Provider Remittance Advice with complete details was sent on March 25, 2020 which was after the initial correspondence received on March 03, 2020 and after the Waiver of Liability received on March 19, 2020.  The Plan states you will need to submit a new appeal request for date of service February 26, 2020. In regard to January 8, 2020, the Plan further states they also need the Medicare Explanation of Benefits prior to processing the claim. The Plan states while the services were unrelated to the reported diagnosis for hospice care, Original Medicare is still responsible for payment under the fee-for-service benefit. The fee-for-service benefit is the time where the enrollee revokes hospice until the start of the new month. During this time Original Medicare is still responsible for payment of medical services both unrelated and related to the hospice diagnosis. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. For services provided that are not directly related to the hospice care, an Explanation of Benefits must be provided by Original Medicare showing the unrelated service was reviewed and denied payment by their office. In this case, the enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.The Plan has not received an explanation of benefits to show Original Medicare has reviewed and denied payment of this service. Based on Medicare billing guidelines, this is required before the Plan can determine payment. Therefore, we decided that the Plan does not have to pay for vision services provided to the enrollee on January 8, 2020at this time.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 3, 2020 by an out-of-network provider.You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you do not have out-of-network benefits.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 provider is not in-network and your EOC clearly states, services are only covered when received by a participating provider.Therefore, we decided that the Plan does not have to pay for the dental services provided on January 3, 2020 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that you cannot get up from your power wheelchair so you need the elevate function to transfer.The Plan denied your request. The Plan says Medicare guidance says that a seat lift does not serve a medical purpose.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is statutorily not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and sleeve provided to the enrollee on
September 26, 2019.
You asked the Plan to pay for the orthosis and sleeve. The Plan denied your request. The Plan says that they
were unable to discover any evidence of an established relationship between the member and the ordering
physician.
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 for the knee orthosis and sleeve
provided to the enrollee on September 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (73630, Q0092 and R0070) provided on December 31, 2019.
You asked the Plan to pay for the radiology services. You say that you would like reconsideration because these services were billed correctly. The Plan denied your request. The Plan says Medicare rules for payment of this claim have not been met due to a missing modifier and inappropriate place of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the radiology services are not supported in the record. Specifically, payment for the technical component of these services is the responsibility of the facility to any vendor. Carriers may not pay for the TC of radiology services furnished to Skilled Nursing Facility inpatients during a Part A covered stay. CPT code 73760 has a PC/TC indicator of 1, meaning it requires the 26 modifier for payment. CPT codes Q0092 and R0070 have a PC/TC indicator of 3, meaning they are technical component only codes. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (73630, Q0092 and R0070) provided on December 31, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee from July 12, 2019 to September 26, 2019.
You asked the Plan to pay for out of network physician services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 service 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 physician services provided to the enrollee from July 12, 2019 to September 26, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the radiation therapy provided on December 10, 2019.
You asked the Plan to waive the coinsurance for the radiation therapy. You say that you cannot afford the coinsurance amount. You say you were never informed that you would have to pay. 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 20% coinsurance for each Medicare-covered radiation therapy service. You have been asked to pay a total of $1,682.19 which is 20% of the allowed amount for the radiation therapy. The allowed amount is $8,410.96. ($8,410.96 x 20% = $1,682.19). The radiation therapy falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 radiation therapy provided on December 10, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care from November 12, 2019 through December 7, 2019.
You asked the Plan to waive the copayment for SNF care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received SNF care from November 12, 2019 through December 7, 2019. You spent a total of 25 days in the SNF. For days 1-20 there was a $0 copayments assessed. For days 21-25 there was a $160.00 copayment applied to each day which totaled to $800.00. 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 SNF care from November 12, 2019 through December 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the alveoloplasty in conjunction with extractions (D7310),
first 15 minutes of deep sedation/general anesthesia (D9222), three subsequent 15 minute increments of deep
sedation/general anesthesia (D9223 x3), consultation (D9310), and therapeutic parenteral drug (D9610)
provided on January 9, 2020.
You asked the Plan to pay for the alveoloplasty in conjunction with extractions, deep sedation/general
anesthesia services, consultation, and therapeutic parenteral drug. You say that you needed to have extractions
in order to get your dentures because your teeth were considered unrestorable and infected. You also say that
you needed the deep sedation services due to depression and anxiety. The Plan denied your request. The Plan
says these services are not covered benefits under your dental plan.
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
alveoloplasty in conjunction with extractions (D7310), first 15 minutes of deep sedation/general anesthesia
(D9222), three subsequent 15 minute increments of deep sedation/general anesthesia (D9223 x3), consultation
(D9310), and therapeutic parenteral drug (D9610) provided on January 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage.You asked the Plan to pre-approve additional mileage. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says you are covered for up to 36 one-way trips per calendar year. The Plan says each one-way trip must not exceed 50 miles.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 36 one-way transportation trips per year, not to exceed 50 miles per one-way trip. We looked at your request, the records in the case file, and the rules. The file shows you are requesting an additional 105 miles per one-way trip. The Plan's contract clearly only allows 50 miles per one-way trip.Therefore, we decided that the Plan does not have to pre-approve additional mileage.