Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to further reimburse you for the prosthetic eye purchased from an out-of-network (OON) provider.

You asked the Plan to further reimburse you for the prosthetic eye. You say that the Plan should further cover the services received. The Plan denied your request. The Plan says the cost share has processed correctly in this case.

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 20% coinsurance for durable medical equipment.

In this case, the Plan has paid to the OON provider the Medicare allowed amount ($935.67) multiplied by the coinsurance (20%) for a total payment of $733.57. The prosthetic eye falls within the durable medical equipment benefit category. This means the Plan has paid the provider the correct amount and cannot further reimburse you the difference between the billed amount ($2,750) and the Medicare allowed amount ($935.67). 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 further reimburse you for the prosthetic eye purchased from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for debridement (11042).

You asked the Plan to waive the copayment for debridement. You say that this should have been coded as a regular office visit. The Plan denied your request. The Plan says this 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 $250 copayment for Medicare-covered surgery services.

You have been asked to pay a $250 copayment for each visit to the hospital for debridement, which is considered a surgical service. 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 debridement (11042).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided by an out of network (OON) provider.

You asked the Plan to pay for specialist services. You say that you did not know you needed a referral from your primary. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available for these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for specialist services provided 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 resin-based composite (D2331) on tooth #24.

You asked the Plan to pay for the resin-based composite. You say that you would like this service to be covered. The Plan denied your request. The Plan says the restoration benefit has a limit to two in a calendar year. The Plan also says that your history plus this request has gone over this limit.

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, amalgams and resin-based composites are limited to 2 per 1 calendar year. The record shows that you received three resin-based composites (D2331 x3), two of which were covered by the Plan, and your amalgam and resin-based composites benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2331) on tooth #24.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from October 3, 2020, to October 9, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you should not have to pay this copayment because the doctors in the urgent care misdiagnosed you. The Plan denied your request. The Plan says you were charged this copayment 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 $235 copayment per day for days 1-7 for inpatient hospital care. Records show that you were an inpatient in the hospital for six days. You have been asked to pay a $235 copayment per day for the inpatient hospital services, for a total of $1,410 ($235 x 6 = $1,410). 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 services you received from October 3, 2020, to October 9, 2020.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a cervical spine fracture and for atrial fibrillation. Your medical problems are stable.
You do not have complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Additionally, there is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on June 10, 2020.
You asked the Plan to pay for lab testing. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare
denies coverage for all cardiovascular risk assessment testing panels except the basic lipid panel.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a
contract provider are considered approved by the plan unless notice is provided that the services will not be
covered.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or outof-
network with the Plan. The documentation does not include prior notice from the Plan that this testing would
not be covered. Without this information, we cannot determine whether the lab order made constituted plandirected
care. Therefore, the Plan has not shown that its decision to deny payment is correct or justified
according to Medicare rules. Therefore, we decided that the Plan has to pay for laboratory testing provided on
June 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services.

You asked the Plan to waive the copayment for laboratory services. You say that you paid for lab work, but the results were not ready to discuss at your appointment. 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 $10 copayment for each covered laboratory service. 

You have been asked to pay a $10 copayment for the laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from August 1, 2020, through August 31, 2020.
You asked the Plan to waive the copayment for the SNF stay. You say that you had to stay in the nursing home because you were on an IV. You say that you should not be responsible for the copayment. 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 $0 copayment per day for days 1-20, then a $178 copayment per day for days 21-100 for each Medicare-covered SNF stay. You have been asked to pay a total of $2,670 for the SNF stay.
Date of Service
SNF Days
Number of Days
Copayment
Member Liability
July 28, 2020-
July 21, 2020
1-4
4
$0/day
$0
August 1, 2020- August 16, 2020
5-20
16
$0/day
$0
August 17, 2020- August 31, 2020
21-35
15
$178/day
$2,670
TOTAL:
$2,670
The SNF stay falls within the "Skilled nursing facility (SNF) 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 SNF stay provided from August 1, 2020, through August 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like reconsideration because the Prolia is medically necessary. The Plan denied your request. The Plan says the records do not show a description of treatment failure, or contraindication, or adverse side effects, of oral or self-administered drugs for osteoporosis as applicable to the member, that supports IV therapy in lieu of standard oral treatment protocol.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Prolia. Our reviewer says that based on the medical records provided there is no documentation that the enrollee meets Medicare criteria for pre-approval of Prolia. Our physician reviewer found the available medical records do not include a description of treatment failure, or contraindication, or adverse side effects of oral or self-administered drugs for osteoporosis as applicable to the enrollee that supports monoclonal antibodies via subcutaneous injection therapy in lieu of standard oral treatment protocol. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous spacer device.
You asked the Plan to pre-approve these services. You say that this is medically necessary for your condition. The Plan denied your request. The Plan says that there are not enough scientific studies to show that inserting a device to open the narrowed space would be safe and effective for you.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The spacer device remains experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that your condition does not meet Medicare criteria for these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous spacer device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure.

You asked the Plan to pay for the preventive procedure. You say that you would like this claim to be paid in full. The Plan denied your request. The Plan says this service 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 covered under this benefit. Therefore, we decided that the Plan does not have to pay for the preventive procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 21, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
September 14, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.
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 subsequent nursing facility care. 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 subsequent nursing facility care provided on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the recement of a crown (D2920).

You asked the Plan to pay for the recement of a crown. You say that you thought this service would be covered. The Plan denied your request. The Plan says this service is not covered under your benefit plan.

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 recement of a crown (D2920).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on January 8, 2020.
You asked the Plan to pay for the home visit. You say that the treatment received was medically necessary and payment should be granted. The Plan denied your request. The Plan says care must be received from a network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intradialytic parenteral nutritional therapy services provided to the enrollee.

You asked the Plan to pay for the services. You say that with the enrollee's high nutritional needs, he has continued to decline nutritionally and needs more aggressive nutrition support. 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found per the reviewed documentation, the ordering physician states that the beneficiary is on CCPD and states that he has poor appetite and low intake despite consultation with a renal dietitian and use of oral supplements over the "past several months" without improvement in albumin levels or nutritional status. The note states his albumin is 2.8. He also states that his malnutrition is not due to a clinical malabsorptive state. He is able to take food and fluid by mouth. No records of weight loss were provided provided. The review has determined that the enrollee does not meet the criteria for this request.

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 pay for intradialytic parenteral nutritional therapy services provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for laboratory tests provided on October 26, 2020.
You asked the Plan to waive the deductible for laboratory tests. You say that you met the $400 deductible prior to receiving the services. 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 $400 deductible for outpatient diagnostic tests and therapeutic services and supplies. You received laboratory tests on October 26, 2020. The record shows that you had only paid $381.61 toward the $400 deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible amount of $18.39. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time laboratory tests were received on October 26, 2020. Therefore, we decided that the Plan does not have to waive the deductible for laboratory tests provided on October 26, 2020.