Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80307 and G0483) provided on
November 19, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The
records show that the specimen was obtained in POS 11. Based on this information, we decided that Medicare
rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not
have to pay for the laboratory services (80307 and G0483) provided on November 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental membership fee (D9999) periodontal maintenance (D4910) localized delivery of antimicrobial agents (D4381) periapical, each additional x-ray (D0230) periapical, first x-ray (D0220) and limited oral exam (D0140) provided March 30, 2019 to September 18, 2019.You asked the Plan to pay for the dental services. You say that you request a total reimbursement o3 $329, which includes the amounts of $223 that was paid by your in office dental plan and $106 because the plan representative told you the claim was processed incorrectly.The Plan denied your request. The Plan says the dental membership fee  is not a covered benefit by Original Medicare or the plan. The full amount that the enrollee paid for the dental services was reimbursed and no further reimbursement is due.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The health plan contract says that the plan will reimburse the amount paid to the provider for dental services. The plan is not able to reimburse for the discounted amounts for dental services that the not pay to the provider.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested membership fees are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for dental membership fee (D9999) periodontal maintenance (D4910) localized delivery of antimicrobial agents (D4381) periapical, each additional x-ray (D0230) periapical, first x-ray (D0220) and limited oral exam (D0140) provided March 30, 2019 to September 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from February
3, 2020 through February 8, 2020 and February 9, 2020 through February 14, 2020, the ambulance transport
provided on February 9, 2020 and laboratory services provided on February 26, 2020.
You asked the Plan to waive the copayment for the inpatient stays, ambulance transport and laboratory
services. You say that you had to go back several times. You say that you shouldn't be responsible for all
balances. The Plan denied your request. The Plan says the copayments 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 $380
copayment per day for days 1 through 5 for covered hospital care, a $250 copayment for each separate
Medicare-covered ambulance service and a $12 copayment for Medicare-covered lab tests.
You have been asked to pay a total of $3,302 for the inpatient stays, ambulance transport and laboratory
services.
The inpatient stays fall within the "Inpatient hospital care" benefit category. The ambulance transport falls
within the "Ambulance services" benefit category. The laboratory services fall 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 copayment for the inpatient stay provided from February 3, 2020 through
February 8, 2020 and February 9, 2020 through February 14, 2020, the ambulance transport provided on
February 9, 2020 and laboratory services provided on February 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (PILD) (0275T). You asked the Plan to pre-approve percutaneous image-guided lumbar decompression. You say that this is medically necessary.The Plan denied your request. The Plan says this service is covered only under a clinical trial.The Plan must follow Medicare rules. Medicare rules say that PILD will be covered by Medicare when provided in a clinical study under section 1862(a)(1)(E) of the Social Security Act (the Act) through Coverage with Evidence Development (CED) for beneficiaries with LSS who are enrolled in an approved clinical study.The rules also say that Medicare MACs made payments on behalf of MA organizations directly to providers of covered clinical trial services, on a fee-for-service basis.We looked at the file and Medicare rules.The requested procedure must be provided under a clinical study, and coverage of clinical study services are the responsibility of Original Medicare.Based on this information, we decided that Medicare rules for coverage of percutaneous image-guided lumbar decompression have not been met.Therefore, we decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (PILD) (0275T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the services are 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 IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on July 7, 2019 by an out of network (OON) provider. You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says there are in-network providers available for these services. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of areaurgent 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 July 7, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient behavioral health hospital admission. You asked the Plan to pre-approve inpatient behavioral health hospital admission. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been met. 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 inpatient behavioral health hospital admission. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on review of the records provided, you do not meet the criteria for acute inpatient mental health treatment as you were not shown to be a danger to yourself or others. You were without agitation or aggression and without perceptual disturbance including auditory, visual hallucinations or delusions. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient behavioral health hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient behavioral health hospital admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tooth extractions.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says six extractions are approved; further extractions exceed the benefit limit.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 covers six tooth extractions per calendar year. The requested services are tooth extractions. The Plan has approved six extractions, per your supplemental dental benefit. Further extractions are not covered by Medicare or the Plan. The extractions are not covered by your medical benefit because they are not being done to prepare the jaw for radiation treatment. Therefore, we decided that the Plan does not have to pre-approve tooth extractions.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the electromyogram provided by on January 17, 2020.You asked the Plan to reduce the copayment for the electromyogram. You say that you were told you would have a $45 copayment for the service.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for each Medicare-covered outpatient hospital visit. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $300 copayment for the electromyogram.You have been asked to pay a $294.48 copayment for the electromyogram. The electromyogram falls within the "Outpatient hospital services" benefit category. The record shows you were billed by the outpatient hospital for this diagnostic test.This means that you have beenasked 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 reduce the copayment for the electromyogram provided on January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (E1399) purchased on January 20, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the DME. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the plan cannot pay a provider who is not eligible to participate in Medicare. 
 
Medicare rules say no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider and supplier enroll in the Medicare program. 
 
The requested provider in this case is not a network provider with the Plan, nor are they eligible to participate in Medicare. 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 durable medical equipment (E1399) purchased on January 20, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for mental health services provided on December 20, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for mental health services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The
plan says that there are in-network providers available.
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 mental health services provided on December 20,
2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (K0800).
You asked the Plan to pre-approve a power operated vehicle. You say that you have many health conditions and cannot manually wheel your wheelchair around. The Plan denied your request. The Plan says your needs can be met with a manual wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day. The file shows that you are able to effectively self-propel a manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 400 OneTouch Ultra test strips for a 50 day supply. 
 
You asked the Plan to pre-approve OneTouch Ultra test strips. You say that the records provided should support medical necessity of the requested services. The Plan denied your request. The Plan says the plan has approved the allowable of 168 for 50 days. The remaining 232 exceeds the allowable and is not medically necessary. 
 
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 OneTouch Ultra test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve 400 OneTouch Ultra test strips for a 50 day supply.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 28, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for vision care services. You say that the provider said they were participating with the Plan. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and 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 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 January 28, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the medical eye exam and the Part B drug
provided on September 5, 2019.
You asked the Plan to waive the cost share for the medical eye exam and the Part B drug. You say that the
claim was incorrectly denied as out-of-network. You say that the provider is in-network. The Plan denied your
request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35
copayment for each in-network Medicare-covered exam and 10% coinsurance for each in-network Medicarecovered
Part B drug.
You have been asked to pay a $35 copayment for the medical eye exam and $192.04 which is 10% of the
allowed amount for the Part B drug. The allowed amount is $1,920.40. ($1,920.40 x 10% = $192.04).
The medical eye exam falls within the "Physician/Practitioner services, including doctor's office visits" benefit
category. The Part B drug falls within the "Medicare Part B prescription drugs" benefit category. The record
shows that the claim was processed using the in-network benefit rates.
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 share for the medical eye exam and the Part B drug provided on
September 5, 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 3,
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 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pentasa. You asked the Plan to pre-approve the Pentasa. You say that the drug is medically necessary. The Plan denied your request. The Plan says coverage for this drug is not available 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 pre-approve Pentasa. Benefits for the Pentasa 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health services to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve outpatient mental health services. You say that you had no luck with innetwork therapists. You say that this therapist helps but is a financial burden. The Plan denied your request. The Plan says there are in-network providers available for these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 outpatient mental health services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that you would like reconsideration because you are having trouble with your liver. The Plan denied your request. The Plan says the record does not indicate that you have a diagnosis of diabetes or renal disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Deluxe Lenses (V2702) provided February 6, 2020.You asked the Plan to pay forthe Deluxe Lenses. You say that you did not know the lenses were not covered.The Plan denied your request. The Plan says Deluxe lenses are not eligible for coverage.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear.Therefore, we decided that the Plan does not have to pay for Deluxe Lenses (V2702) provided February 6, 2020.