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

 
We decided that the Plan does not have to waive the copayment for the visual field vision examination 
provided on August 17, 2020. 
 
You asked the Plan to waive the copayment for the visual field vision examination. You say that the provider 
told they wouldn't charge you for the test. 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 $45 
copayment for Vision Care.  
 
You have been asked to pay a $45 copayment for the field vision test. The field vision test falls within the 
Vision 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 visual field vision 
examination provided on August 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for urology services provided from June 16, 2020 to August 5, 2020.
You asked the Plan to waive the coinsurance for specialist services. You say that when meeting with a Plan representative, you decided that the Plan covers 100% of your bills. The Plan denied your request. The Plan says the coinsurance amounts you are being charged are correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for urology services. The allowed amounts of these claims total $1,239.34, resulting in a total coinsurance obligation of $247.87. You have been asked to pay 20% coinsurance for specialist services. Specialist services fall 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 coinsurance for urology services provided from June 16, 2020 to August 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model with calibrated gradient pressure.

You asked the Plan to pre-approve the pneumatic compressor. You say that the pneumatic compressor medically necessary, and basic compression causes risk of swelling. The Plan denied your request. The Plan says the enrollee does not meet LCD criteria.

The Plan follows Medicare rules. Medicare rules say that the beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve with a four-week trial.

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 pneumatic compressor. Our reviewer says that the pneumatic compressor is not medically necessary. Our physician reviewer found the documentation does not support that the enrollee in this case has lymphedema extending onto the chest, trunk and/or abdomen.

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 pneumatic compressor have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model with calibrated gradient pressure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vectibix. 
 
You asked the Plan to pre-approve Vectibix. You say that Vectibix is an approved drug for the enrollee. The 
Plan denied your request. The Plan says the drug is not being used for a medically-accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Vectibix. Our physician reviewer found 
that the enrollee has metastatic bladder cancer. Despite any molecular testing, there is no compendia basis or 
literature support for Vectibix in bladder cancer. The documentation does not support that the requested drug is 
safe and effective and otherwise reasonable and necessary for this enrollee 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vectibix have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vectibix.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation and complete series of intraoral x-rays provided on July 8, 2020.You asked the Plan to pay forthe comprehensive oral evaluation and complete series of intraoral x-rays. You say that both the office staff and dental hygienist confirmed that your insurance was valid on this date of service.The Plan denied your request. The Plan says benefits for these services have been satisfied and the frequency limitations have been exceeded.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, comprehensive oral evaluation is limited to one procedure every three years, and full mouth or panoramic x-rays are limited to one procedure every five years. The record shows that you received a comprehensive oral evaluation and a panoramic x-ray on December 18, 2019, and your comprehensive oral evaluation and full mouth or panoramic x-rays benefits have been exhausted.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation and complete series of intraoral x-rays provided on July 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS HF device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes do not show enrollment in an approved category B investigational device 
exemption study. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical 
study is needed to determine the efficacy and safety of this device. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS HF device for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department visit for the evaluation and
management of a patient (99283) services provided between 10:00 p.m. and 8:00 a.m. at 24-hour facility, in
addition to basic service (99053) provided June 29, 2020.
You asked the Plan to pay for the emergency visit. You say that please see attached notes and medical records
stating that this enrollee went into the emergency room on this date was seen by the ER physician for a
medically necessary procedure. The Plan denied your request. The Plan says services rendered to incarcerated
members are not payable by the Medicare program.
The Plan must follow Medicare rules. Medicare rules say that services rendered to incarcerated members are
not payable by the Medicare program since the state or local government has a financial obligation to pay for
the cost of healthcare items and services.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the emergency visit have not been met. Therefore, we decided that the Plan does not have to pay
for emergency department visit for the evaluation and management of a patient (99283) services provided
between 10:00 p.m. and 8:00 a.m. at 24-hour facility, in addition to basic service (99053) provided June 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast revision surgery. 
 
You asked the Plan to pre-approve the requested services. You say that the surgery is medically necessary. The 
Plan denied your request. The Plan says the requested surgery is not clinically needed, or medically necessary 
at this time. 
 
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 requested services. Our physician 
reviewer found that you had breast reduction surgery in Mexico. You continue to have healing wounds on your 
breasts. Additional breast revision surgery at this time would result in the risk of repeat wound breakdown and 
non-healing. Therefore, the requested surgery is not medically reasonable or necessary at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve breast revision surgery.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says it is not clear how the enrollee will benefit from transferring to a lower level of 
care to complete therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
setting.
 
 

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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on December 28, 2019, to December 30, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you did not think that you would be charged for this. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $340 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care/in-network. You have been asked to pay a $340 copayment per day for days 1-2 for an inpatient hospital stay. The total amount you are being asked to pay is $680 ($340x 2 days = $680). An inpatient hospital stay falls within the inpatient hospital care/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on December 28, 2019, to December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic parenteral drugs, two or more administrations 
(D9612), deep sedation/general anesthesia (D9222), deep sedation/general anesthesia (D9223) and extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal 
flap if indicated (D6912) provided. 
 
You asked the Plan to pay for therapeutic parenteral drugs, deep sedation and extraction. You say that the 
service was medically necessary. The Plan denied your request. The Plan says the services are not covered 
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. Benefits received out-of-
network are subject to any in-network benefit maximums, limitations, and/or exclusions. You may be billed by 
an out-of-network provider for any amount greater than the payment made by the Plan to the provider. Any 
service not listed in the Plan?s EOC are not covered services. 
 
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. Specifically, you received the services from an out-of-network 
provider and are responsible for the difference in cost. Also, therapeutic drugs and deep sedation are not 
covered benefits.   
 
 
Therefore, we decided that the Plan does not have to pay for therapeutic parenteral drugs, two or more 
administrations (D9612), deep sedation/general anesthesia (D9222), deep sedation/general anesthesia (D9223) 
and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated (D6912) provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe x-ray exam, professional component provided on July 7, 2020.You asked the Plan to pay forthe x-ray exam, professional component (72110-26). You say that the enrollee had multiple exams on this date.The Plan denied your request. The Plan says the records only support one review which was paid.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 72110-26isRadiologic examination, spine, lumbosacral; minimum of 4 views, professional component. We find that CPT code 72110 is not supported in the medical record. Specifically, the service is not verified by the submitted documentation. Based on this information, we decided that Medicare rules for coverage of the x-ray exam, professional componenthave not been met.Therefore, we decided that the Plan does not have to pay forthe x-ray exam, professional component provided on July 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the dual-energy X-ray absorptiometry services coded 77080 
provided on June 16, 2020. 
 
You asked the Plan to pay for the dual-energy X-ray absorptiometry services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 77080 is dual-energy X-ray absorptiometry (DXA), bone 
density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine). 
 
We find that CPT code 77080 is not supported in the medical record. Specifically, all charges are combined 
and reported under revenue code 0510 (clinic visit) on TOB 13X (hospital outpatient). Regardless of the 
number of times the enrollee is seen in a given day at a particular provider, the outpatient services should be 
billed only once (i.e., all-inclusive). Based on this information, we decided that Medicare rules for coverage of 
the dual-energy X-ray absorptiometry services have not been met. Therefore, we decided that the Plan does not 
have to pay for the dual-energy X-ray absorptiometry services coded 77080 provided on June 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the clinical information provided 
supports the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of 
LTACH care have not been met. 
 
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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services in the LTACH that are not already available at 
the current facility. Our reviewer found that there are no services at the LTACH that the enrollee requires that 
are not already available and covered at the current facility. Our physician reviewer also found that this request 
for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care 
may be considered soon. 
 
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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe gingival irrigation (D4921) provided on June 22, 2020.You asked the Plan to pay forthe dental service. You say that you have your teeth cleaned every threemonths. You say that you did not see your normal hygienist that you normally do. You also say that you think that you were billed for the wrong service.The Plan denied your request. The Plan says the records support the service that was billed. The Plan also says gingival irrigation is not listed as a covered service.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 forthe gingival irrigation (D4921) provided on June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for denture replacement received on May 11, 2020. 
 
You asked the Plan to pay for the dentures. You say that you cannot eat without the lower denture. The Plan 
denied your request. The Plan says that this claim was processed correctly, as replacement of a prior denture 
that is unserviceable and cannot be made serviceable. 
 
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 dentures once 
every five years. 
 
The case file indicates that you lost your dentures that you received in 2015. This is more than five years ago. 
The plan's rule regarding denture replacement - "initial placement or replacement of a prior denture that is 
unserviceable and cannot be made serviceable is not a covered benefit" - is not a relevant denial rationale in 
this case, as you lost your dentures. There is no mention of rules regarding lost dentures in the Evidence of 
Coverage. The plan has not provided you any dentures - the previous dentures were received under a different 
contract number. Based on this information, we decided that the Plan's rules for coverage of the dentures have 
been met. Therefore, we decided that the Plan has to pay for denture replacement received on May 11, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided, by an out-of-network (OON) provider.

You asked the Plan to pay for office visit. You say that this service was provided with no adequate timeframe to obtain authorization for this service.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 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 medical services provided by an out-of-network (OON) provider.