Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care following an elective left shoulder arthroplasty, for the enrollee.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the left shoulder arthroplasty is approved but an inpatient admission is not reasonable and medically necessary.

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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the provided records do not support this low-risk enrollee requiring inpatient services before or after this procedure which is relatively low-risk. There was no expected or likely complications or special circumstances to justify inpatient admission. Therefore, this request for such will be considered not medically necessary based on the documentation provided. If the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital care following an elective left shoulder arthroplasty, for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on November 18, 2019.

You asked the Plan to pay for the physical therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were submitted untimely.

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 physical therapy services was not filed until December 8, 2020. 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 physical therapy services provided on November 18, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit provided on June 29, 2020.

You asked the Plan to pay for the outpatient office visit. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the outpatient office visit provided on June 29, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).

You asked the Plan to pre-approve Euflexxa. You say that you have tried and failed Monovisc. The Plan denied your request. The Plan says rules for coverage have not been met because not all step therapy agents have been trialed.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Euflexxa. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found that there is no documentation of prior injection with Orthovisc or Monovisc.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One injections.

You asked the Plan to pre-approve the Gel-One injections. You say that this is a medically necessary treatment. The Plan denied your request. The Plan says this drug is to be picked up at the pharmacy and brought to the office for administration. As such, this is not eligible for coverage under Medicare Part B.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Gel-One injections.

Benefits for the Gel-One injections 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tub stool or bench (E0245).

You asked the Plan to pre-approve a tub stool or bench. You say that you are afraid to fall in the shower. The Plan denied your request. The Plan says rules for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a tub stool or bench (E0245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites and amalgam provided on October 15, 2020, and October 30, 2020.

You asked the Plan to pay for the resin-based composites and amalgam. You say that you believe these services should be covered. The Plan denied your request. The Plan says your annual benefit limit has been reached.

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 Plan offers an annual $500 supplemental dental services benefit limit. The record shows that you met the annual maximum benefit while processing the claim for the October 15, 2020 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the two resin-based composites and amalgam provided on October 15, 2020, and October 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 15, 2019.

You asked the Plan to pay for the services provided. You say that it was not your choice who got on the ambulance. The Plan denied your request. The Plan says the claim processed correctly.

The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services.

The Plan has confirmed that the provider at issue does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes and inserts (A5500 and A5513).

You asked the Plan to pre-approve diabetic shoes and inserts (A5500 and A5513). You say that the requested diabetic shoes and inserts (A5500 and A5513) are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested diabetic shoes and inserts (A5500 and A5513).

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 diabetic shoes and inserts (A5500 and A5513). Our reviewer says that the enrollee does not meet criteria for the requested diabetic shoes and inserts (A5500 and A5513). Our physician reviewer found the documentation does not reveal that the enrollee has had an in-person visit with a physician during which diabetes management is addressed within 6 months prior to delivery of the shoes/inserts. There are no objective physician notes from a Certifying Physician, defined as a doctor of medicine (M.D.) or a doctor of osteopathy (D.O.) who has been diagnosing and treating the enrollee's diabetic systemic condition through a comprehensive plan of care. The enrollee does not meet the above LCD Criteria for the requested diabetic shoes and inserts (A5500 and A5513). 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of diabetic shoes and inserts (A5500 and A5513) have not been met. Therefore, we decided that the Plan does not have to pre-approve diabetic shoes and inserts (A5500 and A5513).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the diagnostic testing provided on October 27, 2020.

You asked the Plan to waive the copays for the testing services. You say that you should have been advised of the excessive cost. The Plan denied your request. The Plan says you are responsible for the copay.

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 $160 copay for each Medicare-covered radiological diagnostic service.

The file shows that you received a duplex scan of extremity veins, a duplex scan of the lower extremity arteries, and a non-invasive physiologic study. You have been asked to pay a $160 copay for each of the testing services. The services fall within the outpatient diagnostic tests 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 copays for the diagnostic testing provided on October 27, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on October 30, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you were told to go to the ER. You say that you are being asked to pay two unnecessary bills and the charges should be dropped. 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 $90 copayment per visit for Medicare-covered emergency care. You have been asked to pay a $90 copayment for the ER visit. The ER visit falls 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. Therefore, we decided that the Plan does not have to waive the copayment for the ER visit provided on October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on October 13, 2020.

You asked the Plan to waive the coinsurance for an injection. You say that you did not have to pay for this before. The Plan denied your request. The Plan says the correct coinsurance 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 15% coinsurance for Medicare Part B prescription drugs/in-network.

You have been asked to pay a 15% coinsurance of the allowed amount for an injection. The total allowed amount is $13.84. The total amount you are being asked to pay is $2.08 ($13.84 x 20% = $2.08). An injection falls within the Medicare Part B prescription drugs/in-network 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 provided by a participating provider on October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 2, 2019.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the physician's services. 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 physician's services provided on December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve HBOT services (CPT code (s): 99183, G0277), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says this is not covered for this enrollee's condition.

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 physician reviewer found the enrollee does not have a nationally covered indication for the treatment with HBOT based on the documentation provided. It does not appear that sufficient standard basic wound care was utilized enough to consider additional strategies for treating his pressure ulcers. Therefore, the HBOT will be considered not medically necessary at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve HBOT services (CPT code (s): 99183, G0277), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment for tooth #12 and abutment supported porcelain/ceramic crown for tooth #12 provided on October 1, 2020.

You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain/ceramic crown. You say that you feel that these services should be covered. The Plan denied your request. The Plan says these services are not covered benefits for tooth #12.

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. The contract clearly states that implant services are only covered for anterior (front) teeth. Tooth #12 is a posterior (back) tooth, and implant services are not covered for posterior teeth. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment for tooth #12 and abutment supported porcelain/ceramic crown for tooth #12 provided on October 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on September 11, 2020.
You asked the Plan to pay for drug testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The service at issue was billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on September 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and full-mouth intraoral x-rays (D0210) provided on November 24, 2020.

You asked the Plan to pay for the oral evaluation and complete x-rays. You say that the Plan confirmed with you that this provider is in-network and you had coverage for x-rays, cleaning, and an oral exam. The Plan denied your request. The Plan says You were already provided with a comprehensive oral exam and full-mouth x-rays in 2019. Each of these services can only be covered once every three plan years.

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 were provided in a frequency that exceeds the Plan's benefit. Documentation was provided to show that you had a complete intraoral x-ray series and comprehensive exam in 2019, which is less than three plan years prior. Please note that periodic exams and bitewing x-rays are different services than the ones provided, and these are each covered once per year. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and full-mouth intraoral x-rays (D0210) provided on November 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Determination of refractive state (92015) provided December 7, 2020.
You asked the Plan to pay for the refraction. You say that you would like the service covered. The Plan denied your request. The Plan says the service was not provided as a routine service and therefore is not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided as part of a routine eye exam. We looked at the file and the Plan's rules. The eye refraction was not performed during a routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the refraction have been met. Therefore, we decided that the Plan does not have to pay for the Determination of refractive state (92015) provided December 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for chiropractic visits provided on October 26, 2020 and October 30, 2020.
You asked the Plan to waive the copayments for chiropractic visits. You say that you were not able to finish your first session and had to come back on another day, and you were charged for another visit even though the first procedure was not completed. The Plan denied your request. The Plan says the copayment amounts you are being charged are 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 $5 copayment for each in-network chiropractic visit. There were 2 visits, resulting in a total copayment amount of $10. You have been asked to pay $5 copayment for each chiropractic visit. Chiropractic visits fall within the Chiropractic 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 copayments for chiropractic visits provided on October 26, 2020 and October 30, 2020.