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

We decided that the Plan does not have to pre-approve dental services (D6752, D2950, D6252).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says bridges are only covered as a a benefit when they replace one missing anterior tooth.

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. The Plan covers the services
when the services are medically necessary and reasonable.

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 services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found the requested
service is for the replacement of two posterior teeth (#29 and 30) with a fixed bridge. Coverage for a fixed
bridge applies only to a single maxillary anterior tooth or to two adjacent mandibular teeth.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve dental services (D6752, D2950, D6252).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the back brace provided on September 17, 2020.

You asked the Plan to waive the coinsurance for the back brace. You say that you were told there would be no charge for the brace. The Plan denied your request. The Plan says you have been asked to pay 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 20% coinsurance for in-network Medicare-covered benefits.

You have been asked to pay $301.09 which is 20% of the allowed amount for the back brace. The allowed amount is $1,505.47. ($1,505.47 x 20% = $301.09). The back brace falls within "Durable medical equipment (DME) and related 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 the back brace provided on September 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, each additional intraoral periapical x-ray, and panoramic x-ray provided on February 24, 2021.
You asked the Plan to pay for the intraoral periapical x-rays and panoramic x-ray. You say that you were not aware that these x-rays would not be covered prior to receiving these services. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first
intraoral periapical x-ray, each additional intraoral periapical x-ray, and panoramic x-ray provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the hair removal procedure (CPT code 17999).

You asked the Plan to pre-approve the hair removal procedure. You say that you need the hair removal
procedure before you move on to the surgery from male to female. The Plan denied your request. The Plan says
the procedure is not covered because it is considered cosmetic.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the hair removal procedure have not been met. The procedure is
not covered because the procedure is considered cosmetic (treatment to improve a person's look). Your doctor's
notes show that you would like hair removed. However, the request is denied because your doctor's notes do
not show that this procedure is medically needed. Therefore, we decided that the Plan does not have to preapprove
the hair removal procedure (CPT code 17999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested user-adjustable heel height feature coded as L5990.

You asked the Plan to pre-approve the adjustable heel height component. You say that it is felt this is a necessary feature. The Plan denied your request. The Plan says all other components were approved; however, L5990 is not covered.

The Plan follows Medicare rules. Medicare rules say that a user-adjustable heel height feature is not medically reasonable and necessary. 

Although this feature may be appropriate, it is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve the requested user-adjustable heel height feature coded as L5990.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyewear provided on March 10, 2021.

You asked the Plan to pay an additional amount for the eyewear. You say that you do not agree with the
processing of the claim. The Plan denied your request. The Plan says you are responsible for any amount over a
$100 retail price for a frames and lens package. A check was sent to you for $100 on April 12, 2021.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
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 Plan sent you a check for $100 on
April 12, 2021, which is the eyewear benefit allowance. Therefore, we decided that the Plan does not have to
pay an additional amount for eyewear provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on July 17, 2020.

You asked the Plan to pay for 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 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 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 services provided on July 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the surgery is necessary. The Plan denied your request. The Plan says the service is considered experimental and investigational.

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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records indicate that the enrollee has lumbar spinal stenosis and neurogenic claudication. The record does not indicate that the enrollee's pain is relieved in flexion. The record does not include the magnetic resonance imaging (MRI) report of the recent imaging to demonstrate the pathology. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the removal of a permanent pacemaker pulse generator with replacement of a pacemaker pulse generator (33228) provided on January 4, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $305 copayment for Medicare-covered surgical services in an outpatient hospital setting.

You have been asked to pay a $305 copayment for the Medicare-covered surgery provided in an outpatient hospital setting. 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 removal of a permanent pacemaker pulse generator with replacement of a pacemaker pulse generator (33228) provided on January 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit and to pay for the self-administered drugs provided from September 27, 2020, to October 5, 2020.

You asked the Plan to waive the copayment for the emergency room visit and to pay for the self-administered drugs. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received emergency care services on the dates of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan. The Plan says that the self-administered drugs you received are not covered under your Medicare Part B benefit.

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 $120 copayment for Emergency care. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room services from September 27, 2020 to October 5, 2020. You have been asked to pay a $120 copayment for the emergency room services. The emergency room services fall within the Emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 

The rules also say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs provided here are not among the types which are covered by Medicare Part B.

Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit and to pay for the self-administered drugs provided from September 27, 2020, to October 5, 2020.

Benefits for the self-administered drugs 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 pay for the services provided by an out-of-network provider on February 25, 2021.

You asked the Plan to pay for 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 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 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 services provided by an out-of-network provider on February 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80053, 85025, 80061, and 83036) provided on July 15, 2020.
You asked the Plan to pay for codes 80053, 85025, 80061, and 83036. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (80053, 85025, 80061, and 83036) provided on July 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the enrollee is still inpatient and needs to be discharged to SNF as the enrollee needs assistance for rehabilitation for acute condition. The Plan denied your request. The Plan says the stay is not medically necessary.

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 meet the Centers for Medicare and Medicaid Services (CMS) coverage criteria for an SNF admission. The enrollee is stable with no new medical problems with no nursing needs and the enrollee has not had a change in function to require daily skilled therapies. The enrollee's rehab needs do not need daily therapies in an inpatient setting as requested in an SNF. Hence, the SNF admission does not meet CMS coverage criteria. The enrollee's rebab needs can be met with home health (HH) care with therapies at home. 

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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the bladder surgery provided on March 2, 2021.

You asked the Plan to waive the copayment for the bladder surgery. You say that you would like this copayment waived for payment. The Plan denied your request. The Plan says the cost share has processed 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 $475 copayment for outpatient hospital services. 

You have been asked to pay a $475 copayment for the bladder surgery. This service falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the bladder surgery provided on March 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from March 7, 2021, through March 12, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you received bad service and do not feel you should have to pay the charges. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $492 copayment per day for days 1-4. for inpatient hospital care. 

You have been asked to pay a $492 copayment per day for days 1-4 for inpatient hospital care. The services at issue fall within the inpatient hospital care benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided from March 7, 2021, through March 12, 2021.

Your complaint about the service you received 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on March 16, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the rest home visit. You say that the doctor was not responsible to get authorization. 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. Therefore, we decided that the Plan does not have to pay for the rest home visit provided on March 16, 2021 by an out-of-network (OON) provider.
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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a hip fracture after a fall. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient 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. There is not a reasonable expectation that this patient 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Bio-Ice (A9900) provided on June 20, 2020.

You asked the Plan to pay for Bio-Ice. You say that this was medically necessary and separately payable. The Plan denied your request. The Plan says this cannot be paid as billed.

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 pay for Bio-Ice (A9900) provided on June 20, 2020.

Benefits for Bio-Ice 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral periapical first radiographic image (D0220) and periapical each additional radiographic image (D0230) provided on March 3, 2021.

You asked the Plan to pay for dental codes D0220 and D0230. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental codes D0220 and D0230 are not covered under the Plan's supplemental dental 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, dental codes D0220 and D0230 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral periapical first radiographic image (D0220) and periapical each additional radiographic image (D0230) provided on March 3, 2021.