Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Relion Prime test strips.  You asked the Plan to pre-approve Relion Prime test strips. You say that the enrollee needs the requested items, which she has been using for some time and which she prefers. The Plan denied your request. The Plan says coverage for diabetic supplies is limited to their preferred brands.  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and may limit the DME to only those preferred brands and manufacturers.  We looked at the file and Medicare rules. The requested test strips are not from a preferred provider. There is no evidence that the enrollee has tried and failed the Plan's preferred brand of test strips. The records do not demonstrate that the preferred glucose test strips cannot be used for medical reasons. Based on this information, we decided that Medicare rules for coverage of Relion Prime test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Relion Prime test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implants (D6010), bone replacement graft for ridge preservation - per site (D7953) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided September 7, 2021.
You asked the Plan to pay for the endosteal implants, bone replacement graft and tooth extraction. You say that these services were necessary. The Plan denied your request. The Plan says you did not have supplemental dental coverage at the time of this services, and these services are not covered under your 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.
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 surgical placement of implant body: endosteal implants (D6010), bone replacement graft for ridge preservation - per site (D7953) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided September 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day sensor.
You asked the Plan to pre-approve a Freestyle Libre 14 Day sensor. You say that the records provided supports
the need for the requested device. The Plan denied your request. The Plan says the records do not show that the
enrollee's insulin requires frequent adjustment based on blood glucose testing results.
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section.
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 a Freestyle Libre 14 Day sensor. Our
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is
currently using insulin glargine and is injecting insulin one time per day.
The enrollee's insulin treatment regimen does not require frequent adjustment based on blood glucose testing
results. The enrollee is not treated with three or more daily administrations of insulin or a Medicare-covered
continuous subcutaneous insulin infusion pump. The enrollee's insulin treatment regimen does not require
frequent adjustment by the enrollee on the basis of testing results.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a Freestyle Libre 14 Day sensor have not been met. Therefore, we decided that
the Plan does not have to pre-approve a Freestyle Libre 14 Day sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost-sharing for vision care services provided on August 17, 2021.  You asked the Plan to waive the cost-sharing for the vision care services. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 Vision care.       You have been asked to pay a $35 copayment for the vision care services. Vision care services fall within the Vision 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 cost-sharing for vision care services provided on August 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional days for inpatient psychiatric admission.
You asked the Plan to pre-approve inpatient psychiatric admission. You say that the requested inpatient
psychiatric admission is medically necessary. The Plan denied your request. The Plan says the requested
inpatient psychiatric admission does not meet criteria.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 psychiatric admission. Our
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee does not
meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of
February 21, 2022 forward. The enrollee could have been treated in a lesser restrictive setting as he was not
showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing
any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety.
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 psychiatric admission have not been met. Therefore, we decided that
the Plan does not have to pre-approve additional days for inpatient psychiatric admission.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three home health physical therapy (PT) visits.
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. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 the enrollee had a fall in August of
2021 with left knee and left ankle surgery. Home health services were initiated on September 20, 2021. As of
February 14, 2022 she was modified independent with rolling, sitting up, and lying down. She needs modified
assist to stand up and sit down. She is non-ambulatory and wheelchair-bound. She does not have documented,
ongoing, skilled PT needs. She appears to have reached her baseline level of function. Home health PT services
are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The
services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve three home health physical therapy (PT) visits.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an x-ray (71046) provide on October 25, 2021.  You asked the Plan to waive the copayment for the x-ray. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided. There was no record of a written order sent to the provider to have these services rendered as a screening, therefore they are ineligible to be considered a screening procedure.  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 $50 copayment for Outpatient diagnostic tests and therapeutic services and supplies.     You have been asked to pay a $50 copayment for the x-ray. X-rays 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 an x-ray (71046) provide on October 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on April 13, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.  The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.   We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have the waive the copayment for the lymphoscintigraphy procedure (code
38792) you had at an outpatient hospital facility on September 15, 2021.
You asked the Plan the waive the copayment for the lymphoscintigraphy procedure. You say that this was not a
surgery, just an injection. The Plan denied your request. The Plan says you were charged this copayment
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 $350
copayment for outpatient surgery and services provided at hospital outpatient facilities.
You have been asked to pay a $350 copayment for the lymphoscintigraphy procedure. According to Medicare,
services with procedure code 38792 are considered surgical procedures. That is why the lymphoscintigraphy
procedure falls within the outpatient surgery and services provided at hospital outpatient facilities benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have the waive the copayment for the lymphoscintigraphy procedure (code
38792) you had at an outpatient hospital facility on September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the provisional crown- further treatment or completion of
diagnosis necessary prior to final impression (D2799) provided September 22, 2021.
You asked the Plan to pay for the provisional crown. You say that the office told you this type of crown is
usually covered, and you did not have time to confirm coverage. The Plan denied your request. The Plan says
this service is not covered under your 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.
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
provisional crown- further treatment or completion of diagnosis necessary prior to final impression (D2799)
provided September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 2, 2021 by a non-
network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The referring provider is not a
network provider with the Plan. The Plan 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 the laboratory services provided on April 2, 2021 by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network vision services provided to the enrollee on
June 28, 2021.
You asked the Plan to pay for out of network 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 must 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 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 out of network vision services provided to the
enrollee on June 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital services you received from July 31, 2021, to August 2, 2021.
You asked the Plan to waive the coinsurance for the inpatient hospital services. You say that these services were charged at the out-of-network rate even though you had no control over who provided these services. You said that this cost sharing should be waived. The Plan denied your request. The Plan says this coinsurance was charged correctly. The Plan says that it did initially process this claim as out-of-network. However, they have since reprocessed it and made additional payment towards these services. You are now only being asked to pay 4% coinsurance for these services.
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 4% coinsurance for inpatient hospital care with an in-network provider.
You have been asked to pay 4% coinsurance for the inpatient hospital services. 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 inpatient hospital services you received from July 31, 2021, to August 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (80053, 80061, 82728, 83721, 83540, 83550) and the routine venipuncture (36415) rendered by the out-of-network (OON) provider on July 23, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the laboratory services (80053, 80061, 82728, 83721, 83540, 83550) and the routine venipuncture (36415) rendered by the out-of-network (OON) provider on July 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided October 5, 2021.  You asked the Plan to waive the coinsurance for the outpatient surgery. You say that the services should be covered. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided.  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 30% coinsurance for Outpatient diagnostic tests and therapeutic services and supplies.        You have been asked to pay a 30% coinsurance for outpatient surgery (allowed amount is $1,232.21 x 20% = $369.66). Outpatient surgeries 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 coinsurance for an outpatient surgery provided October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home visit for the evaluation and management of a new patient (99345) rendered by the out-of-network (OON) provider on August 3, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the home visit for the evaluation and management of a new patient (99345) rendered by the out-of-network (OON) provider on August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incisional biopsy of oral tissue-soft (D7286) provided November 5, 2021.
You asked the Plan to pay for the incisional biopsy. You say that you would like this service covered. The Plan denied your request. The Plan says this service is not covered under your 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.
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 incisional biopsy of oral tissue-soft (D7286) provided November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on September 26,
2021, and September 27, 2021.
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as
they were ap art of your visit. The Plan denied your request. The Plan says you were not considered inpatient
for these services and the copayments are correct as you were in outpatient observation.
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 $25
copayment for Physician/Practitioner services, including doctor's office visits, specifically specialist visits.
You have been asked to pay a $50 copayment for two specialist office visits. 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 office visit provided on September 26, 2021, and September 27, 2021.