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

We decided that the Plan does not have to pay for periodic oral evaluation (D0120), bitewings - four radiographic images (D0274) and prophylaxis - adult (D1110) provided to the enrollee on September 24, 2019 by an in-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 EOC benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The plan reviewed the member's call history. On April 26, 2019 the member reached her $1,000.00 maximum with the processing of the claim for April 2, 2019. As well as meeting her maximum allowed of $1,000.00 the member also exceeded the limitation for service D0274 (bitewings - four radiographic images). Per the plan's supplemental dental rider, the member is allowed one set per plan year and she previously received service D0274 on March 19, 2019. Therefore, we decided that the Plan does not have to pay for periodic oral evaluation (D0120), bitewings - four radiographic images (D0274) and prophylaxis - adult (D1110) provided to the enrollee on September 24, 2019 by an in-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance supplies provided on April 13, 2019.
You asked the Plan to pay for the air ambulance supplies (A0398). You say that the service was medically necessary. The Plan denied your request. The Plan says the supplies are considered part of the general ambulance service and payment for them is included in the payment rate for the transport.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.
We looked at the file and Medicare rules. Ambulance supplies are not separately payable. Based on this information, we decided that Medicare rules for coverage of the air ambulance supplies (A0398) have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance supplies provided
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe CardioMEMS HF implant system for the enrollee.You asked thePlan to pre-approvethe system. You say that this is medically necessary.The Plan denied your request. The Plan says this is not considered to be medically reasonable and necessary based on the quality of evidence in the public domain.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 system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental and investigational.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 system have not been met.Therefore, we decided that the Plan does not have to pre-approvethe CardioMEMS HF implant system for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Prostate test provided on October 22, 2019.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this test was not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Prostate testing is covered when the above criteria are met.
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 testing. Our reviewer says that the requested Prostate test was not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 73-year-old male with benign prostatic hyperpasia with lower urinary tract symptoms. Symptoms have improved with finasteride and alfuzosin. He was found to have elevated PSA of 4.3 ng/mL. He has not had a prostate biopsy. The coverage criteria of L37733 are not met. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Prostate test provided on October 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in-network rates for the core buildup, including any pins when required, and endodontic therapy provided on November 7, 2019.
You asked the Plan to pay the in-network rates for the core buildup and endodontic therapy. You say that the Plan documents of your 2019 benefit coverage do not make a distinction between the coverage for services performed by in-network versus out-of-network providers. You also say that you contacted the Plan before receiving the services, and were not told that there would be a lesser coverage if the services were rendered by an out-of-network provider. The Plan denied your request. The Plan says you were charged correctly. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.
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, you must pay a 50% coinsurance for each of these services when they are received by an out-of-network provider. You must also pay the difference between the billed amount and allowed amount.
Service
Billed Amount
Allowed Amount
50% coinsurance
Difference of Billed & Allowed Amount
Member Liability
Core Buildup
$380
$114
$57
$266
$323
Endodontic Therapy
$1,250
$518
$259
$732
$991
TOTAL:
$1,314
Therefore, we decided that the Plan does not have to pay the in-network rates for the core buildup, including any pins when required, and endodontic therapy provided on November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network provider at the in-network rate.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are available from network providers at the in-network rate.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $75 copayment for out-of-network visit to a specialty physician for Medicare-covered medical care or surgery services in a physician's office. You are not a network provider with the Plan. If the enrollee chooses to receive services with you, they will be asked to pay a $75 copayment for these services. These services fall within the out-of-network visit to a specialty physician for Medicare-covered medical care or surgery services in a physician's office benefit category. This means that the enrollee will be asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. The Plan has network providers from which the enrollee may receive services at the in-network rate. Therefore, we decided that the Plan does not have to pre-approvea referral to an out-of-network provider at the in-network rate.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided June 11, 2019 to June 14,
2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically
necessary. The Plan denied your request. The Plan says that services could have been provided on an outpatient
basis.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably
expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span
two midnights.
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 been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided June 11, 2019 to June 14, 2019.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 13,
2019 through August 14, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was 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 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 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 review has determined that the record showed that at the time of inpatient
admission the admitting physician reasonably expected that the patient's necessary hospital care (including
earlier emergency department (ED) and/or observation care) would span two midnights.
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 pay for the acute inpatient hospital care provided from August 13, 2019 through August
14, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 10, 2019.
You asked the Plan to pay for the ambulance services. You say that stretcher transportation was deemed required to move the patient to their destination safely without causing any more discomfort for the patient. The Plan denied your request. The Plan says that a physician's office/clinic/outpatient center is not a covered destination.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided from October 8, 2019 through November 5, 2019. You asked the Plan to waive the copayment for wound debridement. You say that you thought you would only have one copayment. You say that you don't agree with being charged each visit. The Plan denied your request. The Plan says the copayments 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 $125 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital. You have been asked to pay a $125 copayment for each wound debridement visit. The total amount you owe is $500 ($125/visit x 4 visits = $500). Wound debridement falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 wound debridement provided from October 8, 2019 through November 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home access ramp.You asked the Plan to pre-approve the ramp. You say that this is needed as it is difficult for the enrollee to use his stairs.The Plan denied your request. The Plan says this is not a Medicare-covered item.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home and be primarily medical in nature. The item at issue in this appeal is for use outside of the home. A ramp also does not directly treat a medical condition and is a self-help item. Although this may be appropriate, Medicare does not provide coverage for home access ramps.Therefore, we decided that the Plan does not have to pre-approve a home access ramp
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for ambulance services provided on October 10, 2019. You asked the Plan to waive the deductible for ambulance services. You say that you were admitted to the hospital so the deductible should be waived. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount. 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 a $300 deductible for ambulance services. You received ambulance services on October 10, 2019. The record shows that you had paid $0 toward the $300 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $269.91, which is less than the $300 deductible. The item or service you asked the Plan to waive the copayment for falls within the benefit category ambulance services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible for ambulance services for ambulance services. This cost sharing is a contractual obligation that had not been met at the time ambulance services was received on October 10, 2019. Therefore, we decided that the Plan does not have to waive the deductible for ambulance services provided on October 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 26, 2019. You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition. The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the dispensing order reflects the need for the medical equipment. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided November 22,  2019 to November 25, 2019.You asked the Plan to pay forthe SNF services. You say that you feel that the plan should cover for SNF services.The Plan denied your request. The Plan says the 100 days SNF benefit has been exhausted.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from August 14, 2019 to November 21, 2019. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided November 22,  2019 to November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair accessories (transit system and an accessory tray) for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the transit system is used to facilitate travel in a vehicle, and is not covered DME. The accessory tray does not serve a medical need, and is not covered DME.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that durable medical equipment that is not meant for use in the home is not covered. The transit system is meant for travel outside of the home. Therefore, it cannot be covered. Additionally, our MAXIMUS Doctor Consultant found that the accessory tray does not primarily serve a medical purpose. This exceeds the enrollee's medical needs. Therefore, we decided that the Plan does not have to pre-approve wheelchair accessories (transit system and an accessory tray) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the primary care physician (PCP) services
rendered to you on June 20, 2019.
You asked the Plan to waive the coinsurance for these services. You say that you do not feel liable for the
services. The Plan denied your request. The Plan says the coinsurance 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 50% of
the Medicare-allowed amount for an out-of-network primary are provider visit for Medicare-covered services.
Review of the file shows that you received PCP services on June 20, 2019. You have been asked to pay 50% of
the Medicare-allowed amount for these services, for a total of $97.85. These services fall within the out-of-network
primary are provider visit for Medicare-covered 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 coinsurance for the primary care physician (PCP) services rendered to you on June 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS HF system (33289 and C2624).
You asked the Plan to pre-approve a CardioMEMS HF system. You say that this has been FDA approved. The Plan denied your request. The Plan says this has not been proven to be medically effective.
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 a CardioMEMS HF system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. The device should still be considered experimental or investigational and is therefore not reasonable and necessary under Medicare rules. 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 CardioMEMS HF system have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS HF system (33289 and C2624).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140) provided on October 28, 2019 by an out of network provider.You asked the Plan to pay forthe dental service. You say that you were referred to the provider in this case.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says that dental services received out of network 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 and oral exams are covered, dental services that you receive out of network are not covered.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140) provided on October 28, 2019 by an out of network provider.