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

We decided that the Plan does not have to pay for the dental services provided September 17, 2019.

You asked the Plan to pay for the dental services. You say that you would like the services covered. The Plan denied your request. The Plan says these services are not covered because the claim was received more than 12 months after the service was rendered.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the dental services was not filed until January 5, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the dental services provided September 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a leg socket for the approved foot prosthesis.

You asked the Plan to pre-approve a leg socket for the approved foot prosthesis. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that socket replacements are considered reasonable and necessary if there is adequate documentation of functional and/or physiological need.

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 leg socket for the approved foot prosthesis. Our reviewer says that the services are not medically necessary. Our physician reviewer found addition to lower extremity, socket insert, multi-durometer, below knee does not meet Medicare criteria for coverage as this item exceeds your medical need. You do not have a below the knee amputation but rather a partial foot amputation therefore the item 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 a leg socket for the approved foot prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a leg socket for the approved foot prosthesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient medical supplies provided on
December 8, 2020.

You asked the Plan to waive the coinsurance for ostomy supplies. You say that the Plan advised, you would not
pay a copayment for medical supplies while under home health care. The Plan denied your request. The Plan
says the coinsurance you are being charged is correct.

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%
coinsurance for in-network medical supplies.

The allowed amount of the claim is $225.25, resulting in a coinsurance obligation of $22.52. The EOC
confirms that there is a 10% coinsurance for each medical supply. In-network ostomy supplies 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 ostomy supplies (A4409, A4419) provided on December 8, 2020.

Your complaint about the Plan's previous claims processing 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on January 13, 2021 by an OON provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that there is a medical necessity pre-established with the enrollee and the facility for this provider to render services to the enrollees needing care. The Plan denied your request. The Plan says these services were rendered by a non-network provider. The Plan also says that the enrollee was not referred by a network provider, nor were the services approved in advance.
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. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit provided on January 13, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5258) purchased on August 17, 2020.
You asked the Plan to pay for hearing aids. You say that you were advised by the provider that they do not bill insurance directly, but you could be reimbursed by your insurance if you submitted the claim yourself. You know other Medicare recipients have been able to receive reimbursement for hearing aids and do not understand why yours are denied. The Plan denied your request. The Plan says hearing aids are not covered by Medicare, and your plan does not offer a supplemental hearing benefit to cover routine hearing services.
The rules say that Medicare does not cover hearing aids or related services. The Plan follows the same rule and has opted to not provide a supplemental (extra) benefit to cover hearing aids. Though hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pay for hearing aids (V5258) purchased on August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two extractions and two bone replacement grafts for ridge preservation provided from June 8, 2020, to November 23, 2020.
You asked the Plan to pay for the extractions and bone replacement grafts. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services are purely dental in nature, and are unrelated to the limited clinical indications. The Plan also says that these services are not eligible for coverage under the medical benefit.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the two extractions and two bone replacement grafts for ridge preservation provided from June 8, 2020, to November 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says the enrollee
does not require skilled nursing or skilled rehabilitation services. These services are not required daily.
Custodial care is not covered.
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 the SNF services. Our reviewer says
that daily skilled services are not medically necessary. Our physician reviewer found that the enrollee has
stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing
and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at
a lower level of care. Although further rehab services would be appropriate to improve function, as a practical
matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility.
The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding
tube. She is medically stable without any acute exacerbations of chronic medical problems. Her physical
function is at or near her baseline and she can receive services at a lower level of care. Admission to a SNF for
inpatient skilled rehab services 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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical history of hip replacement, cervical fusion and renal artery stents and is living at home with frequent falls. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88305, 88312) provided on January 8, 2021 by an out of network (OON) provider.

You asked the Plan to pay for OON laboratory services. You say that this should be covered. The Plan denied your request. The Plan says this was 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 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 laboratory services (88305, 88312) provided on January 8, 2021 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87086, 81001, 87088, 87186) provided on January 26, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available. 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 had network providers available who could have provided the services 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 these services. Therefore, we decided that the Plan does not have to pay for lab services (87086, 81001, 87088, 87186) provided on January 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection of aflibercept (a Medicare Part B drug) provided on January 21, 2021.
You asked the Plan to waive the coinsurance for Part B drug. You say that this is a financial hardship for you. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.
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 20% coinsurance for Part B drug. The allowed amount of this drug is $1,908.06, resulting in a coinsurance amount of $381.61. You have been asked to pay 20% coinsurance for Part B drug. Part B drug falls within the Medicare Part B Prescription Drugs 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 injection of aflibercept (a Medicare Part B drug) provided on January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services, intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug) (96365, 96366) ferric carboxymaltose injection (J1439) provided December 2, 2020 to December 28, 2020.
You asked the Plan to pay for the outpatient hospital services. You say that you had to have 4 infusions of phosphorus and magnesium as result of being prescribed an iron compound causing an adverse reaction. You do not feel you should be responsible for paying charges connected with any of the infusions. The Plan denied your request. The Plan says the enrollee had not satisfied the 2020 yearly deductible of $1,250 therefore, the claims were processed correctly per the Evidence of Coverage.
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 $1,250 deductible. This is the amount you have to pay out of pocket before the plan will pay their share of covered medical services. The item or service you asked the Plan to pay for falls within the benefit category Outpatient hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,250 deductible. This cost sharing is a contractual obligation that had not been met at the time the outpatient hospital services was received on December 2, 2020 to December 28, 2020. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services, intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug) (96365, 96366) ferric carboxymaltose injection (J1439) provided December 2, 2020 to December 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve a CGM. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CGM. Our reviewer says that the item is not medically necessary. Our physician reviewer found it is not documented what medicine you are taking for diabetes mellitus. 

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 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services rendered on December 29, 2020.
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 are not covered.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 64494 is 1. You billed 2 units of this code, exceeding the MUE. 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 pay for the pain management services rendered on December 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee has a past medical history of COVID 19 infection, lumbar radiculopathy, diabetic neuropathy and is living at home with weakness and difficulty with gait and ambulation. Medical conditions are stable. There are no complex nursing or rehabilitation needs.The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 16, 2020.

You asked the Plan to waive the copayment for the office visit. You say that you received a letter stating all out-of-pocket costs were eliminated and the Plan should pay all costs. 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 $35 copayment for provider and professional services at an in-network specialist's office.

You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan says that only costs for primary care visits, outpatient behavioral health visits, and telehealth visits were being waived. 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 office visit provided on November 16, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the naturopath services rendered from October 9, 2020 to November 4, 2020.
You asked the Plan to pay for these services. You say that the services helped you recover from weight loss. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pay for the naturopath services rendered from October 9, 2020 to November 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) provided on December 29,
2020, by an out of network (OON) 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 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 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 the electrocardiogram (EKG) provided on
December 29, 2020, by an out of network (OON) provider.