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

We decided that the Plan does not have to pre-approve out-of-network services provided to the enrollee on October 12, 2020.
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve out-of-network services provided to the enrollee on October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.

You asked the Plan to pre-approve facet joint injections. You say that the requested procedure is medically necessary. The Plan denied your request. The Plan says the coverage criteria for the requested service have not been met.

The Plan must follow Medicare rules. Medicare rules say that the patient must have documented failure to respond to conservative therapy.

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 facet joint injections. Our reviewer says that the request is not medically necessary and reasonable. Our physician reviewer found this 64-year-old man has chronic low back pain. In this case, there is no documentation of physical therapy/chiropractic services or a home exercise program. In addition, there is no documentation of a Non-steroidal anti-inflammatory drugs (NSAID) trial or why this trial is not appropriate. Therefore, conservative therapy has not been evident as tried 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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the dental services (D0150, D0330, D1110 D1208) received November 18 and December 3, 2020 from the out-of-network provider.

You asked the Plan to pay an additional amount for the dental services. You say that the cost share amount listed for covered in-network and out-of-network services is listed as $0. The Plan denied your request. The Plan says providers are paid based on the Maximum Allowable Charge (MAC). For services covered under the Plan, you may still be billed by an out-of-network provider for any amount greater than the MAC payment made by the plan to the provider.

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 payment is in excess of that which is covered under this benefit. The Plan agreed to pay 100% up to the Maximum Allowable Charge (MAC) for the covered dental services. The Plan contract states on page 4-73 that you may be billed more by an out-of-network provider if the charge is greater than the Plan's MAC. You have been asked to pay the difference between the Plan's MAC and what was charged by the out-of-network provider. 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 pay an additional amount for the dental services (D0150, D0330, D1110 D1208) received November 18 and December 3, 2020 from the out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a physical therapy evaluation visit provided by an otolaryngologist (ear, nose, and throat specialist) on October 19, 2020.
You asked the Plan to waive the copayment for specialist visit. You say that the copayment for this visit should be waived. The Plan denied your request. The Plan says the copayment amount you are being charged is 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 $40 copayment for specialist visit. You have been asked to pay $40 copayment for specialist visit. 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 physical therapy evaluation visit provided by an otolaryngologist (ear, nose, and throat specialist) on October 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolaris prostate cancer assay.
You asked the Plan to pre-approve Prolaris prostate cancer assay. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested services.
The Plan must follow Medicare rules. Medicare rules say that Prolaris prostate cancer assay is only covered when enrollees have a percentage of positive cores less than 50%. Review of the file shows that the Plan uses Local Coverage Determination (LCD) L37082. This LCD is not valid for your home state of Georgia. Therefore, we cannot use LCD L37082 to substantiate our decision.
We looked at the file and Medicare rules. The Prolaris prostate cancer assay is only covered when enrollees have a percentage of positive cores less than 50%. The file shows that you have a percentage of positive cores of 50%. This means you do not have a percentage of positive cores less than 50%. Based on this information, we decided that Medicare rules for coverage of Prolaris prostate cancer assay have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolaris prostate cancer assay.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve routine transportation. You say that you are legally blind and cannot afford transportation to your appointments. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation is correct, because routine transportation beyond 60 one-way trips per calendar year is not covered by the Plan.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implantation of a reflex activation device for the enrollee.
You asked the Plan to pre-approve the procedure. You say that the requested services are not medically necessary. The Plan denied your request. The Plan says this procedure is not proven to improve long term health outcomes.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the BAROSTIM NEO System is indicated for the improvement of symptoms of heart failure for patients who remain symptomatic despite treatment with guideline directed medical therapy, are NYHA Class III or Class II (who had a recent history of Class III), have a left ventricular ejection fraction less than or equal to 35%, a proBNP less than 1600 pg/ml, and excluding patients indicated for Cardiac Resynchronization Therapy (CRT) according to AHA/ACC/ESC guidelines. The enrollee in this case does not have a left ventricular ejection fraction less than or equal to 35%, or documenation of a proBNP of less than 1600 pg/ml. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve an implantation of a reflex activation device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy, anterior tooth (excluding final restoration) (D3310) provided January 4, 2021.
You asked the Plan to pay for the root canal. You say that you have dental benefits for 2021 so the service should be covered. The Plan denied your request. The Plan says root canals are not covered under your dental 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. 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 endodontic therapy, anterior tooth (excluding final restoration) (D3310) provided January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage of abscess provided on June 18, 2020.
You asked the Plan to pay for the incision and drainage of abscess. You say that you believe this service should be covered at 50%. 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 incision and drainage of abscess provided on June 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen equipment (E0431, E1390) provided on December 20, 2020.
You asked the Plan to waive the coinsurance for oxygen equipment. You say that you had a positive COVID-19 test and thought that anything that had to do with COVID-19 was fully covered. The Plan denied your request. The Plan says the correct coinsurance was 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 20% coinsurance for durable medical equipment, oxygen/oxygen equipment, and related supplies. The Plan has attested that the COVID-19 Emergency Declaration policy does not apply to the rental of oxygen equipment. You have therefore been asked to pay $28.52, or 20% of the Medicare-allowed amount of $142.65, for oxygen equipment. Oxygen equipment falls within the "Durable medical equipment (DME) and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for oxygen equipment (E0431, E1390) provided on December 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder, elbow, and hip x-rays rendered on April 26, 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 services are 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 tests at issue in this appeal, shoulder, elbow, and hip x-rays, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the shoulder, elbow, and hip x-rays rendered on April 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950)
provided January 6, 2021.
You asked the Plan to pay for the core buildup. You say that you were not aware the service was not covered
and cannot afford the cost. The Plan denied your request. The Plan says the services is not covered under your
dental 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.
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 core
buildup, including any pins when required (D2950) provided January 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of 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 leg infection and had a below the knee amputation Medical problems are stable. There are no 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. 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 acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth services provided on December 3, 2020 by an out of network (OON) provider.

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 services were rendered by an out-of-network provider without 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 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 telehealth services provided on December 3, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on December 22, 2020.

You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the Plan.

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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for ophthalmological services provided on December 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Imfinzi rendered on June 1, 2020.

You asked the Plan to waive the coinsurance for these services. You say that you disagree with the denial. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for all other Part B drugs at an outpatient hospital setting.

Review of the file shows that you received Imfinzi on June 1, 2020. You have been asked to pay a 20% coinsurance for these services. These services fall within the all other Part B drugs at an outpatient hospital setting 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 Imfinzi rendered on June 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the computed tomography of the abdomen and pelvis (74176) and the computed tomography of the thorax (71250) provided on January 5, 2021.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 copayment for computed tomography (CT) scans provided by your primary care physician in their office. Additionally, you pay a $295 copayment for CT scans performed by a provider other than your primary care physician. 

You have been asked to pay a $295 copayment ($131.65 + $163.35) for the computed tomography services provided. These are the Plan allowed amounts which are less than the applicable copayments for these services. 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 the computed tomography of the abdomen and pelvis (74176) and the computed tomography of the thorax (71250) provided on January 5, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care supplies provided on March 20, 2020.
You asked the Plan to pay for the wound care supplies. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 wound care supplies provided on March 20, 2020.