Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 16, 2018.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.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 carefrom 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 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 forthe medical services provided to the enrollee by an out-of-network provider on November 16, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram and breast biopsy provided on October 11, 2019.You asked the Plan to waive the copayment forthe mammogram and breast biopsy. You say that you are being charged for a procedure that was unsuccessful. You say that another procedure will be needed so you should not be responsible for thecharges.The Plan denied your request. The Plan says the claims were reprocessed to only apply copayments.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 $10 copayment for diagnostic lab services and diagnostic procedures and tests and a $10 copayment for each basic imaging service. You have been asked to pay a $10 copayment for the mammogram and a $10 copayment for the breast biopsy. The mammogram and breast biopsy 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 basedon 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 forthe mammogram and breast biopsy provided on October 11, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the aortic ultrasound provided on June 6,
2019.
You asked the Plan to waive the copayment for the aortic ultrasound. You say that you are at risk for an
abdominal aortic aneurysm and your plan should allow one ultrasound covered at 100% every year. 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 $250
copayment per day for Medicare-covered diagnostic radiology services. For this date of service, you have been
asked to pay the allowed amount of the claim because this amount is less than the $100 copayment for the
ultrasound.
You have been asked to pay a $62.46 copayment for the aortic ultrasound. The aortic ultrasound falls within
the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for the aortic ultrasound provided on June 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe porcelain crown provided on July 3, 2019.You asked the Plan to pay forthe crown. You say that the crown was placed on your tooth because the tooth had nerve damage and you were in pain.The Plan denied your request. The Plan says this service is not covered under your contract under any normal circumstances.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 forthe porcelain crown provided on July 3, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis, the shoulder-elbow-wrist-hand orthosis, the knee orthoses and suspension sleeves provided on March 19, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis (L0650), the shoulder-elbow-wrist-hand orthosis (L3960), the knee orthoses (L1851) and suspension sleeves (L2397). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says rules for telehealth services were not met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis, the shoulder-elbow-wrist-hand orthosis, the knee orthoses and suspension sleeves provided on March 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laboratory services to be provided. You asked the Plan to pre-approve the laboratory services. The Plan denied your request. The Plan says the laboratory services can be performed by the network provider. 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 laboratory services to be provided by provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are available in-network.
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 medical 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 pay for the assistant surgeon services provided to the enrollee on September 25, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says assistant surgeon services are not covered for this procedure.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 20610. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the services have not been met.Therefore, we decided that the Plan does not have to pay forthe assistant surgeon services provided to the enrollee on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the provider is not in the network.

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 a referral to an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient admission for an approved total knee replacement surgery.You asked the Plan to pay for the inpatient admission. You say that it is felt this should be approved as inpatient.The Plan denied your request. The Plan says outpatient admission is appropriate and can be changed to inpatient should the need arise.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient admission. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the enrollee is scheduled for unilateral total knee arthroplasty (TKA). The treating orthopedist identified no medical conditions which were expected to complicate the procedure and noted that no medical clearance would be needed. The record does not show that the admitting physician reasonably expects that the patient's necessary hospital care (including earlier ED and/or observation care) will span two midnights based on her medical condition. Inpatient admission is not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient admission have not been met.Therefore, we decided that the Plan does not have to pay for acute inpatient admission for an approved total knee replacement surgery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on October 16, 2019.
You asked the Plan to waive the copayment for the ultrasound. You say that your copayment is usually $50. You say that you were not expecting to pay more. The Plan denied your request. The Plan says the copayment 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 $100 copayment for diagnostic radiology. You have been asked to pay $96.09, which is less than the standard $100 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound provided on October 16, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Rituximab.
You asked the Plan to pre-approve the Rituximab. You say that the records provided support the need for the requested drug. The Plan denied your request. The Plan says that the records do not show that the enrollee has a condition for which Rituximab is covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Rituximab. Our reviewer says that the criteria for coverage of the requested drug have been met. Our physician reviewer found the documentation does support that the Rituximab is medically reasonable and necessary for the enrollee. The enrollee has a diagnosis of autoimmune encephalitis. She has failed to respond to intravenous steroid therapy and to intravenous immunoglobulin therapy. Second line therapies include Rituximab. The documentation supports that the Rituximab is safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Rituximab have been met. Therefore, we decided that the Plan has to pre-approve Rituximab.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve various power wheelchair accessories for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary for the proper functioning of the approved power tilt. The Plan denied your request. The Plan says this 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 asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the K0108 push bar is not medically necessary as it does not serve a pure medical purpose. The right and left leg rests and leg rest receivers (K0108) are not medically necessary as swing away leg rests are already included with the approved power tilt system and components. There are numerous requested K0108 items such as the harness seat interface and backrest assembly, gas strut, semi recline fastener, back cover shell power recline, home switch, power recline actuator harness, back hardware for recline actuator. These items are not medically necessary for the enrollee's illness or to improve a malformed body member as they are already included in the approved items. The documentation additionally does not reveal a medical need for a replacement actuator. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve various power wheelchair accessories for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on October 28, 2019.
You asked the Plan to pay for the periodontal maintenance. You say that this cleaning was one of the two cleanings that you schedule per year. The Plan denied your request. The Plan says this service is not a covered benefit.
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 periodontal maintenance provided on October 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long-term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services that the enrollee needs can be provided in anothersetting, such as an acute rehab facility, skilled nursing facility, outpatient setting, or home care.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for COPD and an empyema. The enrollee underwent surgical drainage of her lung infection. The enrollee is not currently intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-termcare needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid fitting/checking (V5011) on August 1, 2019.
You asked the Plan to pay for the hearing aid fitting/checking. You say that you have not seen the doctor since 2016 and needed your hearing aids adjusted in order to hear better. You feel that you should be reimbursed. The Plan denied your request. The Plan says based on not receiving covered hearing aids and having adjustments to hearing aids that had been previously received, this service is not eligible for coverage.
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. The Plan pays for hearing aids only fitting evaluations are limited to 1 per covered hearing aid. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid fitting/checking have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid fitting/checking (V5011) on August 1, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist office visit provided on October 3, 2019.You asked the Plan to waive the copayment fora specialist office visit. You say that this was a post-op visit. You say that you were told that you would not have a copayment for this visit.The Plan denied your request. The Plan says the correct copayment has been 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 $50 copayment for physician/practitioner services/specialist visits. You have been asked to pay a $50 copayment for a specialist office visit. Post-op office visits are still subject to a copayment; therefore, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/specialist 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 waive the copayment fora specialist office visit provided on October 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, topical application of fluoride varnish, and periodic oral evaluation provided on September 24, 2019.You asked the Plan to pay for the prophylaxis, topical application of fluoride varnish, and periodic oral evaluation. You say that you do not feel you should have paid for the total service because you were not aware that this provider did not accept your insurance.The Plan denied your request. The Plan says they called and confirmed with the provider that they do not accept Medicare or participate with any insurance plans. The Plan also says that payment to a Non-Medicare provider is prohibited.The Plan must follow Medicare rules.The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation. This provider has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay for the prophylaxis, topical application of fluoride varnish, and periodic oral evaluation provided on September 24, 2019