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

We decided that the Plan does not have to pre-approve two removals of torus mandibularis (D7473 x2).
You asked the Plan to pre-approve the removals of torus mandibularis. You say that these procedures are medically necessary so you can get lower dentures that fit your mouth. The Plan denied your request. The Plan says this service is 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 two removals of torus mandibularis (D7473 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas device therapy and vitamin injections (97032,
97750, 96372, 97150, J3490, J3411, J3415, J3490, J7999, 97139) provided on March 9, 2021.
You asked the Plan to pay for the Sanexas device therapy and vitamin injections. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare does not
cover Prolotherapy.
The Plan must follow Medicare rules. Medicare rules say that in order for physician-provided drugs to be
covered, the medical records must document the name of the drug administered as well as the dosage. The rules
also say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or
under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a
nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy
services under State law.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Sanexas device therapy and vitamin injections have not been met. Payment for HCPCS/CPT
codes J3490, J3411, J3415, J3490, J7999 and 96372) is not supported. Specifically, the record does not contain
documentation of the dosage and type of drug administered in each injection, which is required by Medicare
for these services to be reimbursed.
Additionally, after review of the file and publicly available records, we find that the physical therapy services
at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of
Oklahoma.
Therefore, we decided that the Plan does not have to pay for the Sanexas device therapy and vitamin injections
(97032, 97750, 96372, 97150, J3490, J3411, J3415, J3490, J7999, 97139) provided on March 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided August 19, 2021.  You asked the Plan to waive the copayment for the non-emergency ambulance services and ground mileage. You say that the hospital arranged transportation. 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 $175 copayment for each Medicare-covered ground ambulance service.     You have been asked to pay a $175 copayment for the non-emergency ambulance services and ground mileage. The non-emergency ambulance services and ground mileage falls 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 the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided August 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oxygen concentrator (E1390) and portable gaseous oxygen system (K0738).

You asked the Plan to pre-approve the Oxygen concentrator and portable gaseous oxygen system. You say that the items are medically necessary. The Plan denied your request. The Plan says authorization for oxygen equipment is limited to 36 monthly rental payments and you have used 36 months of this service as of March 14, 2021.

The Plan must follow Medicare rules. Medicare rules say that reimbursement for oxygen equipment is limited to 36 monthly rental payments. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Oxygen concentrator and portable gaseous oxygen system have not been met. Therefore, we decided that the Plan does not have to pre-approve the oxygen concentrator (E1390) and portable gaseous oxygen system (K0738).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third opinion consultation and follow-up visit to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a third opinion consultation and follow-up visit to be rendered by the out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hearing test provided on
October 19, 2021.
You asked the Plan to waive the copayment for the hearing test. The Plan denied your request. The Plan says
the in-network allowed amount for this service is $31.00. Since the allowed amount is less than the copayment
amount of $40.00, your member cost share was determined to be the lesser value of $31.00.
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 Hearing Services.
You have been asked to pay the lesser value of a $31.00 copayment for the hearing test. The hearing test falls
within the Hearing Services benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for a hearing test provided on October 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty hospital bed.
You asked the Plan to pre-approve a heavy-duty hospital bed. You say that this item is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of a heavy-duty hospital bed.
The Plan must follow Medicare rules. The rules state that for Medicare to cover a heavy-duty hospital bed, the enrollee must weigh between 350 and 600 pounds. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a heavy-duty hospital bed have not been met. Specifically, the record shows that you do not meet Medicare weight requirements, for coverage of the requested item. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased on September 20, 2021.

You asked the Plan to pay for the eyewear. You say that the service should be covered. The Plan denied your request. The Plan says you have exhausted your Plan's maximum allowance for this service.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when with a $250 allowance for eyewear; if the eyewear you purchase costs more than the allowance listed, you pay the difference. 

We looked at the file and the Plan's rules. You have exhausted your Plan's maximum allowance for this service. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear purchased on September 20, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on June 4, 2021.

You asked the Plan to waive the copayment for an emergency room visit. You say that you never received care because of the wait time you went home. The Plan denied your request. The Plan says the proper copayment was applied.

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 $65 copayment for Emergency care per visit.

You have been asked to pay a $65 copayment for an emergency room visit. An emergency room visit falls within the Emergency care 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 an emergency room visit provided on June 4, 2021.

Your complaint about your experience with this provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus testing provided on October 12, 2021.
You asked the Plan to pay for the services provided. You say that the clinic because they guaranteed results in
time for travel. The Plan denied your request. The Plan says the services were paid at the Medicare allowable
amount.
The Plan must follow Medicare rules. Medicare rules say that a bill for assigned services is considered paid in
full when the Medicare allowed amount is paid.
We looked at the file and the rules. The records show that the Plan reimbursed the testing at issue based on the
Medicare allowed amount. Based on this information, we decided that Medicare rules for coverage have not
been met. Therefore, we decided that the Plan does not have to further pay for the coronavirus testing provided
on October 12, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on
August 18, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER on August 18
and stayed until the next day. You feel that you should not be responsible for two days since it took so long.
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 $110
copayment for each emergency room visit.
You have been asked to pay a $110 copayment for the ER visit. Please note that although your visit extended to
the following day, only one copayment apples since it was considered a single visit. The ER visit falls within
the Emergency Care 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 an emergency room
(ER) visit provided on August 18, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth service provided on February 16, 2021.

You asked the Plan to waive the copayment for a telehealth service. You say that you should not be responsible for copayments during the height of coronavirus, and it was only a 15-minute phone call. The Plan denied your request. The Plan says the proper copayment was applied.

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 telehealth visits.

You have been asked to pay a $40 copayment for a telehealth service. Telehealth services falls within the Outpatient mental health care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a telehealth service provided on February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the resin-based composite of one surface (D2330) or pay more for the resin-based composite of four or more surfaces (D2335) provided on September 29, 2021.  You asked the Plan to pay for the resin-based composite of one surface and to pay more for the resin-based composite of four or more surfaces. You say that you would like to appeal these services. The Plan denied your request. The Plan says your annual dental benefit limit for 2021 has 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, the Plan offers a $500 annual dental benefit maximum. The record shows that you met the annual maximum benefit while processing the claim for the September 29, 2021 date of service and your annual maximum benefit for 2021 has been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite of one surface (D2330) or pay more for the resin-based composite of four or more surfaces (D2335) provided on September 29, 2021.   Your complaint about your disappointment in the Plan's coverage is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on October 4, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that you wanted a tooth repaired where a filling had fallen out and the dentist required an exam beforehand to assess the tooth. The Plan denied your request. The Plan says this service is 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.  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. The only types of exams that are covered under your dental benefit are routine oral exams and comprehensive oral exams. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on October 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on September 15, 2021.  You asked the Plan to waive the copayment for the inpatient hospital care. You say that the service should be covered. The Plan denied your request. The Plan says the cost share 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 $325 copay for each admission for inpatient hospital care.   You have been asked to pay a $325 copay for each admission for the inpatient hospital care. the inpatient hospital care falls within the inpatient hospital care 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 hospital care provided on September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable concentrator (E1390).
You asked the Plan to pre-approve a portable concentrator. You say that the item is medically necessary. The
Plan denied your request. The Plan says authorization for oxygen equipment is limited to 36 monthly rental
payments and you have used 36 months of this service as of April 3, 2021.
The Plan must follow Medicare rules. Medicare rules say that reimbursement for oxygen equipment is limited
to 36 monthly rental payments.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a portable concentrator have not been met. Therefore, we decided that the Plan does not have to
pre-approve a portable concentrator (E1390).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied
your request. The Plan says the enrollee does not meet Medicare criteria for coverage of SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found based on the medical records provided this
patient does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in
a lower level of care would be appropriate.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says the criteria is not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses
adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections.
Based on this information, we decided that Medicare rules for coverage of the monitor have not been met.
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) (K0553) and supplies (K0554).
You asked the Plan to pre-approve the CGM and supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says the member does not meet the criteria for these items.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) (K0553) and supplies (K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmological services to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve ophthalmological services to be rendered by the out-of-network (OON) provider.