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

We decided that the Plan does not have to pay for the bone replacement graft (D7953) provided on November 11, 2019.
You asked the Plan to pay for the dental services. You say that the service was necessary due to the extensive damage to your mouth. You say that had you had the procedure done at a later day it would have been more extensive and costly. The Plan denied your request. The Plan says the bone replacement graft 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 bone replacement graft is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone replacement graft (D7953) provided on November 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scalings and root planings (D4341) of the lower left and lower right quadrants provided on October 1, 2019.
You asked the Plan to pay for the scalings and planings. You say that you were not aware of the time limit and thought you could have this service done every year. You also say that the provider did not inform you of this time limit either. The Plan denied your request. The Plan says this treatment is covered, but it has a two-year time limit before it can be redone. The Plan also says that the time limit had not yet passed.
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, periodontal scaling and root planning is limited to once per quadrant every 24 months. The record shows that you received periodontal scalings and root planings of the lower left and lower right quadrants on August 31, 2018 and your periodontal scaling and root planing benefit is now exhausted. Therefore, we decided that the Plan does not have to pay for the periodontal scalings and root planings (D4341) of the lower left and lower right quadrants provided on October 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated post and core in addition to crown (D2954).
You asked the Plan to pre-approve the prefabricated post and core in addition to crown. You say that you need to restore tooth #13 for the enrollee with a new prefabricated post and core and new crown. The Plan denied your request. The Plan says this service is not a covered benefit.
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 pre-approve a prefabricated post and core in addition to crown (D2954).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 12, 2018 to the enrollee 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 a non-participating 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 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 on July 12, 2018 to the enrollee by an out of network (OON) provider.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to waive the copayment for ambulance services provided on August 21, 2019.
You asked the Plan to waive the copayment for ambulance services. You say that you live below the poverty line and should not be responsible for the charges. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The Plan contract does not say in clear and accurate terms how much enrollees should expect to pay for ambulance services. The plan contract says enrollee's must pay a $0 copayment or $200 copayment for ambulance services. We looked at the contract between the enrollee and the Plan. We did not see where the contract clearly says when enrollees must pay a $200 copayment for ambulance services. The Plan contract does not clearly say how much enrollees can expect to pay for ambulance services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for ambulance services provided on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spine disk x-ray
You asked the Plan to pre-approve the x-ray. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is supported for spine pain that has been present for more than twelve weeks, that does not travel to other areas of the body.
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 x-ray. Our reviewer says that the requested x-ray is not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is experimental and not medically needed. More research is needed to establish the efficacy and validity of this technique. 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 x-ray have not been met. Therefore, we decided that the Plan does not have to pre-approve a spine disk x-ray.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 22, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require 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 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 physician's services provided on November 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on October 15, 2019.
You asked the Plan to pay for the drug testing. You say that this enrollee receives this testing regularly and it should not be denied. The Plan denied your request. The Plan says payment of over 18 tests within a one year period is not covered without clear documentation of medical necessity. This documentation is not provided.
The Plan must follow Medicare rules. Medicare rules say that there are frequency limits associated with drug testing and that testing over the threshold must be clearly documented as medically necessary. In this case, the Plan has paid for 18 drug tests in the past year. The documentation shows that this testing is being received approximately weekly. The rules say that even for high risk patients, random testing should be done up to 1-3 times during a three-month period. There is no documentation in the record provided to support that testing far beyond this limit is medically reasonable and necessary for this patient's management. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on October 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve the Prolia. You say that the Prolia is medically necessary. The Plan denied your request. The Plan says step therapy rules have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our reviewer says that coverage criteria has not been met. Our physician reviewer found there was no documented trial of the plan preferred drugs, such as an oral bisphosphonate drug (e.g., alendronate, ibandronate, risedronate) or zoledronic acid. The record shows no reason why these drugs would be contraindicated 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 the Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a LINX Reflux Management System esophageal sphincter augmentation (43284).
You asked the Plan to pre-approve a LINX Reflux Management System esophageal sphincter augmentation. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that laparoscopy esophageal sphincter augmentation is considered not reasonable and necessary at this time. We looked at the file and Medicare rules. The requested procedure is considered not medically necessary and is excluded from coverage. Based on this information, we decided that Medicare rules for coverage of a LINX Reflux Management System esophageal sphincter augmentation have not been met. Therefore, we decided that the Plan does not have to pre-approve a LINX Reflux Management System esophageal sphincter augmentation (43284).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 24, 2019 to September 30, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from January 21, 2019 to September 24, 2019. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from September 24, 2019 to September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services.
You asked the Plan to pre-approve the physician's services. You say that you have scar tissue that needs to be removed. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be provided by 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) and the office visits (99203, 99213) rendered by out of network (OON) From October 28, 2019 to November 13, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were provided 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) and the office visits (99203, 99213) rendered by the out of network (OON) provider from October 28, 2019 to November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided on
November 18, 2019.
You asked the Plan to waive the copayment for an eye exam. You say that you disagree with the charges
because the eye exam was related to a previous surgery. The Plan denied your request. The Plan says the claims
were processed correctly, and the enrollee is being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $40 copayment for each outpatient visit to diagnose and treat disease or conditions of the eye.
The enrollee received an eye exam on November 18, 2019. Follow-up eye exams are subject to cost-sharing
charges. Therefore, the enrollee is responsible to pay the $40 copayment.
The enrollee has been asked to pay a $40 copayment for an eye exam. An eye exam falls within the vision care
benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for an eye exam provided on November 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's care could be evaluated and treated in inpatient acute care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH. Initially treated for hemorrhagic cystitis, the enrollee subsequently exhibited respiratory failure and renal failure. The enrollee was intubated/ventilated and eventually received a tracheotomy. The enrollee is not tolerating weaning and appears to have a poor prognosis. 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. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left-sided medial facetectomy (L1-2, L2-3) for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is necessary, despite the MRI improvement. The Plan denied your request. The Plan says given that the ESIs did not provide relief, it is unclear if the neuroforaminal stenosis is the issue.
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 surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a recent trial and failure of PT. There is no correlation between the exam and the MRI findings. Surgery is not needed. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a left-sided medial facetectomy (L1-2, L2-3) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided from September 17, 2019 to October 9, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says there is no authorization 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 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 nurse practitioner services provided from September 17, 2019 to October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.
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 a referral to an out-of-network provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on October 25, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that you should not be responsible for the copayment because you were advised to have a colonoscopy to check for damage from diverticulitis. 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 $400 copayment for surgery services at an in-network ambulatory surgical center. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $400 copayment for the colonoscopy.You have been asked to pay a $373.94 copayment for the colonoscopy. The colonoscopy 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 forthe colonoscopy provided on October 25, 2019.