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

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and extra-oral posterior dental radiographic imaging (D0251) provided on September 14, 2021.  You asked the Plan to pay for the limited oral evaluation and radiographic image. You say that tooth # 18 was broken. You say that you had it removed. You say that you have had to have 2 other teeth removed since then. You say that there was a little piece of the bone in the socket that was removed. You also say that you feel you should not be charged for this. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that extra-oral posterior dental radiographic imaging is not listed as a covered service either.  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 limited oral evaluation and extra-oral posterior dental radiographic imaging are not among those covered under this benefit. Additionally, the record shows that you signed a Payment Policy Agreement stating that you agreed that not all services are a covered benefit in all contracts and that you are responsible for all fees for services rendered to you. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), and extra-oral posterior dental radiographic imaging (D0251) provided on September 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10mg Belsomra tablets.
You asked the Plan to pre-approve 10mg Belsomra tablets. You say that you would like reconsideration
because the requested drug is medically necessary. The Plan denied your request. The Plan says the requested
drug is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 10mg Belsomra tablets.
Benefits for 10mg Belsomra tablets 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral salpingo-oophorectomy to be provided by an
out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that the enrollee needs to see this provider due to
enlarging ovarian mass and consistency of care. The Plan denied your request. The Plan says the services are
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
bilateral salpingo-oophorectomy 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 pay for a telephone visit (99443) provided on June 21, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a telephone visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says these services were not authorized. The Plan also says that this provider is a non-network provider who does not work with the Plan, and the member self-directed for care. The Plan also says that the member's primary care provider (PCP) did not refer for services, and no medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. The Plan also says there is no network deficiency for these services and alternate network providers were found.  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 had network providers available who could have provided 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 a telephone visit (99443) provided on June 21, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for catheter placement for coronary
angiography provided on August 6, 2021.
You asked the Plan to waive the deductible for the catheter placement. You say that you feel that you should
not be responsible since the Plan did not pay anything for the service. The Plan denied your request. The Plan
says the correct amount was applied to your deductible.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is $500 deductible which applies to certain items and services.
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Surgery and
Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not
been met at the time the catheter placement was received on August 6, 2021. Therefore, we decided that the
Plan does not have to waive the deductible for catheter placement for coronary angiography provided on
August 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for an oxygen concentrator provided on July 21, 2021, by an out-of-network provider.  

You asked the Plan to pay for an oxygen concentrator. You say that no authorization is needed for the reimbursement of the oxygen concentrator. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been met.  

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 had network providers available who could have provided 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 an oxygen concentrator provided on July 21, 2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on April 15, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows the referring provider was also out-of-network. Therefore, we decided that the Plan does not have to pay for genetic testing provided on April 15, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for hearing aids provided on August 20, 2021.  You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says there is no coverage if hearing aids, or related services are received from an out-of-network provider.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on August 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services received on September 9, 2021.  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 correctly.  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 the denied codes is:  CPT 77049:  Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral  CPT 77066:  Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral  CPT 82565:  Creatinine; blood  HCPCS A9576:  Injection, gadoteridol, (prohance multipack), per ml  HCPCS G0279:  Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to 77065 or 77066)  HCPCS G0463:  Hospital outpatient clinic visit for assessment and management of a patient  We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found CPT code 77049 has a status indicator of "B" which means -  Status Indicator B indicates a service that's always bundled into another service. Reimbursement of this service is always included in the payment for another service, whether the code is billed on the same date of service as a primary code or billed alone on a different date or claim. Therefore, 77049 is not eligible for reimbursement. Because CPT 77049 was submitted to the Medicare Adv. health plan inappropriately, all other CPT and HCPCS codes billed on the claim denied with an OCE edit code of 0992.  We looked at this coder's review, the file, and Medicare rules. 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 imaging services received on September 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Docetaxel.
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 the services are not covered.
The Plan must follow Medicare rules. The rules say that Original Medicare covers the routine costs of clinical trials.
We looked at the file and Medicare rules. The file shows that the docetaxel is being requested as part of a clinical trial. The Plan cannot approve these services, as Original Medicare covers the routine costs of clinical trials. Therefore, we decided that the Plan does not have to pre-approve Docetaxel.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.
You asked the Plan to pre-approve Eliquis. You say that you would like reconsideration because the requested
drug is medically necessary. The Plan denied your request. The Plan says this drug does is not covered under
Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.
Benefits for Eliquis 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 reduce the copayment for the specialist office visit services provided
by an in-network provider on September 24, 2021.
You asked the Plan to reduce the copayment for the specialist office visit. You say that you have always paid a
$35 copayment at the dermatology. 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 $40
copayment per visit for a specialist.
You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" 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 reduce the copayment for the specialist office visit provided by an in-network provider on
September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services provided on
August 19, 2021.
You asked the Plan to waive the copayment for podiatry services. You say that the charge for the office visit was too much and you have never paid this much. The Plan denied your request. The Plan says the original claim processed with a deductible. The Plan has corrected the claim and removed the deductible and applied the proper copayment 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 Medicare-covered podiatry visit.
You have been asked to pay a $35 copayment for podiatry services. Podiatry services falls within the Podiatry 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 podiatry services provided on August 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor.
You asked the Plan to pre-approve a Dexcom G6 device. You say that the requested item is a medical necessity
for the enrollee. The Plan denied your request. The Plan says rules for coverage for continuous glucose
monitors and related supplies have not been met.
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 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 a Dexcom G6 device have not been met.
Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a mobile cardiac outpatient telemetry (MCOT) monitor.  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 the services are 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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation to support that you have a significant irregular heartbeat (cardiac arrythmia) as a likely cause of your symptoms or that a diagnosis of such could only be made with the use of the MCOT monitor. A 30-day ambulatory electrocardiogram (EKG) monitor has not been performed. The records do not support that the requested MCOT monitor is reasonable and medically necessary at this time.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a mobile cardiac outpatient telemetry (MCOT) monitor.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425).
You asked the Plan to pre-approve ambulance service, basic life support, non-emergency transport and ground mileage. The Plan denied your request. The Plan says denial of coverage for non-emergent ambulance transport and ground mileage was appropriate given the non-covered destination and the EOC does not provide coverage for non-emergent ambulance transportation.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pre-approve are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pre-approve ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two extractions performed by an oral surgeon.
You asked the Plan to pre-approve two extractions performed by an oral surgeon. You say that it is impossible
for a general dentist to extract the teeth due to your medical history and condition. You say that the general
dentist determined you were high risk, and the Plan needs to make an exception to cover these extractions. The
Plan denied your request. The Plan says services must be performed by a participating general dentist.
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, dental services performed by an oral
surgeon are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pre-approve two extractions performed by an oral surgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra.
You asked the Plan to pre-approve Xiidra. The Plan denied your request. The Plan says this is not a covered
benefit.
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 Xiidra.
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 the enrollee is recommended for skilled nursing
facility (SNF) care. The Plan denied your request. The Plan says the denial of authorization for SNF care is
correct.
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 the enrollee does not have daily skilled
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on
an inpatient basis in a skilled nursing facility (SNF) setting.
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.