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

We decided that the Plan does not have to pay for the physician services provided on March 31, 2020 by an out of network (OON) provider.You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.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 has network providers available who can provide 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 physician services provided on March 31, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia for an extraction.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there were no medical or behavioral issues listed to indicate the need for the use of general anesthesia during the dental procedure.
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 anesthesia is not medically reasonable or necessary. Our physician reviewer found, due to a lack of any documented or behavioral issues, the criteria for coverage for the use of general anesthesia have not been met for the extraction of tooth #32. 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 anesthesia for an extraction.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the WATS 3D brush testing provided on October 24, 2019.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that WATS 3D brush biopsy has been proposed as a method to improve the detection of dysplasia during endoscopic surveillance of the esophagus. The documentation does not support a diagnosis of the esophagus in this enrollee. There is insufficient documentation to demonstrate that WATS 3D brush testing was medically reasonable and necessary for the enrollee in this case. 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 WATS 3D brush testing provided on October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis and the wrist hand orthosis provided on October 2, 2019. You asked the Plan to pay for the ankle foot orthosis (L1971) and the wrist hand orthosis (L3916). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says there is no itemized shipping/billing invoice to indicate the specific supplies delivered.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid and proof of delivery for the supplies provided in this case. There is no invoice. Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis and the wrist hand orthosis provided on October 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from October 14, 2019 to October 16, 2019.You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you received a bill of $680, which is more than what you were originally quoted and cannot afford the charges.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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $340 copayment per day for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from October 14, 2019 to October 16, 2019. Therefore, you are responsible to pay a $340 copayment per each day. The total amount you owe is: $340 (copayment) x 2 (inpatient days) = $680. You have been asked to pay the total copayment amount of $680 for an inpatient hospital stay. An inpatient hospital stay falls 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 an inpatient hospital stay provided from October 14, 2019 to October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and the abutment supported crown (D6059) provided on February 10, 2020.You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that the services would be covered despite the provider being out of network. You say that your benefit guide does not say that implant crowns are not covered. You say that you have had numerous implants done, every one of them have needed a cap on it, and every one of them have been partially covered.The Plan denied your request. The Plan says the custom fabricated abutment and abutment supported crown are not listed as covered services. The Plan also says if a service is not listed, then it is 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 listed as covered under this benefit. The Evidence of Coverage clearly states that any services not listed are not covered.Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and the abutment supported crown (D6059) provided on February 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided to the enrollee on December 30, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that this is a financial hardship for the enrollee.The Plan denied your request. The Plan says that the claim processed up to the Medicare allowable fee.The rules saya 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 $285 copay for each covered, one-way ambulance trip by ground or water. The enrollee has been asked to pay a $266.91 copay for the ambulance transport. The ambulance transport falls within the covered, one-way ambulance trip by ground or water benefit category. This means that the enrollee has been asked to pay less than 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.Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided to the enrollee on December 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve disposable underpads (A4554) and adult diapers (T4526)
You asked the Plan to pre-approve the underpads and adult diapers. You say that you need these items and cannot afford to pay for them out of pocket. The Plan denied your request. The Plan says these items are not covered benefits.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve disposable underpads (A4554) and adult diapers (T4526)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility
You asked the Plan to pre-approve IRF care. You say that the medical records should be reviewed, and the authorization should be reconsidered and approved. The Plan denied your request. The Plan says services can be safely received in other settings, for example: a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 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 enrollee was medically stable, with no evidence of need for supervision by the PMR physician. There is no need for acute rehab nursing care. Functionally, the enrollee is at CGA/SBA level, and there is no need for an IRF level of therapy. The enrollee may benefit from PT and OT, but does not require an intensive therapy program. The admission is not medically necessary, based on the enrollee's functional status, and medical stability. 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 admission to an inpatient rehabilitation facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation provided on December 23, 2019.You asked the Plan to pay forthe periodic oral evaluation. You say that you had two preventive exams and one emergency exam. You also say that you do not think that the emergency exam should count toward the frequency limitations for preventive exams.The Plan denied your request. The Plan says your insurance only benefits two oral exams per calendar year. The Plan also says that you had been benefited two oral exams in 2019 prior to the oral exam on December 23, 2019.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, oral examinations are limited to two per calendar year. The record shows that you received a limited oral exam and a periodic oral exam on June 18, 2019 and August 6, 2019 and your oral examinations benefit had been exhausted.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation provided on December 23, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on December 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
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 services was not filed until January 13, 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 services provided on December 17, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve myringotomy for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says that this is considered investigational.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the denial is for "balloon dilation of the eustachian tube" which is considered investigational. In the case summary, the provider requests reconsideration for "myringotomy procedure." The summary of statement for reason for denial states that the "balloon dilation of the eustachian tube" is considered investigational. Then under the conclusion, it states that the requested myringotomy procedure is investigational. However, a myringotomy procedure is completely different and unrelated to a balloon dilation of the eustachian tube. A myringotomy is defined as making an incision in the tympanic membrane. A balloon dilation of the eustachian tube is a procedure which dilates the eustachian tube. These two procedures are not the same thing, and in fact, operate on different parts of the ear. Therefore, the denial does not make logical sense. The fact that a balloon dilation of the ET is considered investigational does not have any bearing on a myringotomy procedure. Myringotomy, with or without PET placement, is not investigational. It is well established as a standard treatment for chronic otitis media, or recurrent acute otitis media. 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 procedure have been met. Therefore, we decided that the Plan has to pre-approve myringotomy for the enrollee.
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 pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee does not have complex medical conditions that require an LTACH level of care.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that the enrollee presented to the acute hospital with bacteremia/sepsis related to infected sacral and ischial pressure sores. He was treated in hospital with surgical debridement and intravenous antibiotics. He is bed-bound and non-ambulatory. He is contracted and requires a Hoyer lift for transfers and he is totally dependent for all activities of daily living. Physical and occupational therapy report no acute skilled need for therapy. He is otherwise medically stable. The acute care hospital is able to provide all of the services the enrollee requires. The enrollee is receiving necessary services and is at an appropriate level of care in the acute care hospital.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient medical services provided on January 10, 2020 by an out of network (OON) provider.You asked the Plan to pay for the OON services. You say that all services rendered to the enrollee were required to maintain health.The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits.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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services.Therefore, we decided that the Plan does not have to pay for the outpatient medical services provided on January 10, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and 2 extractions (D7250) provided on January 31, 2020.
You asked the Plan to pay for x-ray and extractions. You say that you went to a participating provider. You say that comprehensive oral exams are covered once every 3 years. You say there is a 0% coinsurance for dental x-rays. You also say that based on this information, the services you received should be covered. The Plan denied your request. The Plan says the periapical x-ray and extractions are not listed as covered services.
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 dental services are not among those covered under this benefit. The Evidence of Coverage clearly states that bitewing x-rays are the only type of x-rays that are covered. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and 2 extractions (D7250) provided on January 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the pelvis for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical information received shows that the same test or one similar to the requested study has already been performed.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found the bone lesions in the pelvis were imaged already. A bone scan could be considered as clinically indicated. A repeat MRI would not give new 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the pelvis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 26, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because you were not charged at the time services were rendered. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for each specialist office visit. You have been asked to pay a $15 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on December 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lenvima.
You asked the Plan to pre-approve Lenvima. The Plan denied your request. The Plan says the drug is not covered for the enrollee's condition by the Part B plan.
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 pre-approve Lenvima.