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

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on December 17, 2019 by an OON provider.You asked the Plan to pay forthe comprehensive oral evaluation and complete series of intraoral x-rays. You say that you contacted the Plan to choose an approved dental office and doctor. You also say that the Plan representative was not clear on the location of the provider you chose.The Plan denied your request. The Plan says the treating provider is OON. The Plan also says that you have to see in-network providers for coverage.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 covered when they are received OON.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation and complete series of intraoral x-rays provided on December 17, 2019 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites provided on January 14, 2020 by an OON provider.
You asked the Plan to pay for the resin-based composites. You say that you contacted the Plan to choose an approved dental office and doctor. You also say that the Plan representative was not clear on the location of the provider you chose. The Plan denied your request. The Plan says the treating provider is OON. The Plan also says that you have to see in-network providers for coverage.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the resin-based composites provided on January 14, 2020 by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystoscopy provided on March 17, 2020.
You asked the Plan to waive the copayment for the cystoscopy. You say that you have always paid $30 for this procedure. You say you cannot afford the $350 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $350 copayment for an outpatient hospital facility. You have been asked to pay a $350 copayment for the cystoscopy. The cystoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you received this service at an outpatient hospital.
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 cystoscopy provided on March 17, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to hold you harmless for the acute inpatient hospital services provided from February 18, 2020 to February 19, 2020. You asked the Plan to hold you harmless for these services. You say that you were advised to stay overnight for observation. The Plan denied your request. The Plan says that that your care could have been provided at a lower level of care (observation). 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 follows these rules. You were referred for these services by a contract provider. The file does not show that the Plan provided notice that these services would not be covered. Under Medicare rules, this means these services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the acute inpatient hospital services provided from February 18, 2020 to February 19, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study.
You asked the Plan to pre-approve a sleep study. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that sleep studies are only covered for certain indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a sleep study. Our reviewer says that the documentation does not support that the requested sleep study is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of obstructive sleep apnea, and has had a previous Polysomnography (PSG). The enrollee is in need of replacement Continuous positive airway pressure (CPAP) equipment. The records do not indicate any major health changes or sleep issues that would require CPAP re-titration. A new PSG is not medically necessary in order to obtain replacement equipment. Therefore, the enrollee does not meet criteria for the requested 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 a sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for teeth 8 and 10 pontic (D6240) for tooth 9 and crown (D6750) for teeth 8 and 10.You asked the Plan to pre-approve the dental services. You say that the enrollee needs an upper partial to replace missing teeth on posterior as seen lower posterior teeth present and needs posterior teeth for chewing.The Plan denied your request. The Plan says the requested service is not reasonable and medically necessary.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 dental 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 dental services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the overall periodontal condition of the upper arch is one of moderate bone loss with more severe localized areas of loss. There is no indication that periodontal treatment has been performed. Teeth #8 and #10 both show bone loss at about 40% or more. #10 is a lateral incisor which is typically not indicated as a terminal abutment due to its inherently short root. Given the loss of bone on #10 approaching 40%, on what is already a short rooted tooth, it would not appear to be a suitable abutment for a bridge particularly considering the overall periodontal condition of the arch. In a case such as this the periodontal conditions need to be documented and active disease addressed, with mobility measurements being particularly relevant. If a lateral incisor is to be used as a terminal abutment, a strong case supported by evidence must be made of a solid, non-mobile and periodontally stable tooth. The case for the stability of the abutments has not been successfully made, and there is no medical necessity for the requested three-unit bridge. Any core buildups are also not necessary, and would not be in any event as there is insufficient lack of tooth structure as to require it. 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 dental services have not been met.Therefore, we decided that the Plan does not have to pre-approvecore build up (D2950) for teeth 8 and 10 pontic (D6240) for tooth 9 and crown (D6750) for teeth 8 and 10.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on December 5, 2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says that 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 emergency situation, 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 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 a domiciliary, rest home visit provided on December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for personal trainer services provided August 14, 2019 to January 3, 2020.
You asked the Plan to pay for the personal trainer services. You say that the services should be covered and are more beneficial than physical therapy. The Plan denied your request. The Plan says gym memberships or personal training services provided by non-network fitness centers are not covered.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only when obtained from network fitness centers through the program. The Plan's rules for coverage of gym benefits have not been met because the services were obtained from an out-of-network fitness center. Therefore, we decided that the Plan does not have to pay for personal trainer services provided August 14, 2019 to January 3, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for a retrobulbar injection (67500) provided on December 16, 2019.
You asked the Plan to pay for the retrobulbar injection. You say that you would like reconsideration because these services were performed by separate physicians. The Plan denied your request. The Plan says that this surgical code was submitted by a provider with an anesthesia specialty.
The Plan must follow Medicare rules. Medicare rules say that 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. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of 67500 have been met. Specifically, this service was rendered by a provider different than the provider which furnished the anesthesia service, meaning that the PTP edit between the two codes cannot be applied. In addition, the citation from Chapter 8 of the NCCI Policy manual appears to apply to injection codes billed by the provider of the ophthalmic procedure and cannot be applied to services rendered by a CRNA in support of the ophthalmic procedure. The Medicare rules referenced by the Plan do not state that the provider type at issue cannot bill for code 67500. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for a retrobulbar injection (67500) provided on December 16, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided by an RNFA on August 26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not payable for these services.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided by an RNFA on August 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided from January 8, 2020 through January 27, 2020.
You asked the Plan to waive the copayment for wound debridement. You say that due to the care of your previous procedure, you are not responsible for the wound care. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $150 for each visit to an outpatient hospital facility. You have been asked to pay a $150 copayment for each wound debridement visit. The total amount you owe is $600 ($150/visit x 4 visits = $600). Wound debridement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for wound debridement provided from January 8, 2020 through January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames and lenses provided on December 29, 2019.You asked the Plan to pay for the frames and lenses. You say that you should only be liable for services over $300.The Plan denied your request. The Plan says the services were processed correctly.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when received at a network optical provider.We looked at the file and the Plan's rules. The file indicates you did not receive these services at a network optical provider. Based on this information, we decided that the Plan's rules for coverage of the frames and lenses have not been met.Therefore, we decided that the Plan does not have to pay for the frames and lenses provided on December 29, 2019.
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. The Plan denied your request. The Plan says there is no need for comprehensive rehab, or intensive therapy at this time.
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 physician reviewer found that the enrollee is at minimal assist for balance, standby assist for bed mobility, minimal assist for toilet transfers, and minimal assist for dressing. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from additional physical and occupational therapy, but the documentation does not support that her functional level requires an 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the chest.
You asked the Plan to pre-approve CT scan. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the Plan already approved a CT scan and the records do not describe the results of the approved scan or if there are still plans to perform this test.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested CT scan. Our physician reviewer found a CT scan of the chest is medically reasonable and necessary for the enrollee in this case. However, a CT scan of the chest was already approved by the Plan for dates March 13, 2020 to June 11, 2020. Further imaging would depend on the results of the previously approved CT scan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the chest.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visit and the SPECT test provided from January 29, 2020 to February 27, 2020.
You asked the Plan to waive the copayments for the specialist office visit and the SPECT test. You say that you were told by your provider that this would be covered. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $35 copayment for each visit to a specialty physician office and a $200 copayment for each type of Medicare-covered diagnostic radiology service including MRI, CT scans, nuclear scans, and PET scan, per date of service. You have been asked to pay a $35 copayment for the specialist office visit and a $200 copayment for the SPECT test. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The SPECT test falls 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 copayments for a specialist office visit and the SPECT test provided from January 29, 2020 to February 27, 2020.
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. You say that the enrollee cannot be adequately cared for at a skilled nursing facility. The Plan denied your request. The Plan says the enrollee's current needs are being met in the acute setting.
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 is currently undergoing treatment at an acute care hospital (ACH) for a prosthetic hip infection. The enrollee has undergone surgical debridement and is receiving a prolonged course of antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) to be performed by a periodontist.
You asked the Plan to pre-approve the services. You say that you were advised that you need to see a Periodontist due to history of Chemotherapy treatment for over a year and it has affected your teeth and jaw. You state that you were referred to the Periodontist to see which teeth would require extraction. The Plan denied your request. The Plan says this is not covered under Medicare or the Health 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. Medicare does not generally cover dental services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth. Although your plan offers dental benefits that exceed Medicare coverage, the dental coverage is limited to services performed by a participating general dentist. Periodontal services are not covered by your Health Plan for members 21 years and older. Therefore, we decided that the Plan does not have to pre-approve consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) to be performed by a periodontist.