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

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that you have seen this provider before and you would like to continue. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 specialist services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the special supplemental benefits for beneficiaries with chronic diseases.

You asked the Plan to pre-approve the special supplemental benefits.. You say that you are now eligible for these benefits. Your health has deteriorated, months ago your blood pressure elevated and other diagnostic and you should be eligible. The Plan denied your request. The Plan says the enrollee has none of the qualifying diagnoses, does not require intense care coordination, has no high risk for hospitalizations or high risk for adverse health outcomes.

The Plan must follow Medicare rules. Medicare does not cover special supplemental benefits. However, the plan offers a benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply. The enrollee suffers from high blood pressure, and this diagnosis is not included in the list of qualifying diagnoses for the requested benefits. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Special supplemental benefits for the chronically ill have not been met. Therefore, we decided that the Plan does not have to pre-approve the special supplemental benefits for beneficiaries with chronic diseases.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and clinical crown lengthening (D4249) provided on March 11, 2020, and September 10, 2020 by an OON provider.
You asked the Plan to pay for the comprehensive periodontal evaluation and clinical crown lengthening. You say that you were told that these services would be covered by the Plan. The Plan denied your request. The Plan says the total $1,887.80 amount applied correctly as enrollee liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.
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, you are responsible for the difference between the billed amount and allowed amount for the comprehensive periodontal evaluation (D0180) which totals $151. The record also shows that the provider billed $1,800 for the clinical crown lengthening (D4249). The allowed amount for this service is $361. The Plan is responsible for 20% of the allowable amount. You also had $45 of the deductible remaining therefore, plan paid $63.20 ($361 - $45 = $316 * 20%). You are responsible for all fees billed by the provider in excess of the allowed amount, which is $1,736.80 ($1,800 - $63.20) for the clinical crown lengthening. The total enrollee liability amount of $$1,887.80 is correct. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and clinical crown lengthening (D4249) provided on March 11, 2020, and September 10, 2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan.

You asked the Plan to waive the copayment for the CT scan. You say that the deductible and maximum out-of-pocket had been met at the time of service. The Plan denied your request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $150 per day, per in-network provider, for Medicare-covered diagnostic radiology services.

The enrollee has been asked to pay a $150 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show the maximum out-of-pocket had not been met at the time the CT scan was received. 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 the CT scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for oral hygiene instruction (D1330).

You asked the Plan to pay for the dental service. You say that you did not receive this service. You also say that you should not have to pay for it. The Plan denied your request. The Plan says oral hygiene instruction 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 for oral hygiene instruction (D1330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Extraction of erupted tooth (D7210) and Limited oral evaluation - problem focused (D0140) provided November 1, 2020.

You asked the Plan to pay for the tooth extraction and limited oral evaluation. You say that the services were medically necessary, and your cost-share is a hardship. The Plan denied your request. The Plan says the claims were processed correctly.

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. 

You have been asked to pay $98.50 ($197 allowed amount x 50% coinsurance = $98.50) for the tooth extraction. This means that you have been asked to pay the correct amount for the tooth extraction 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 cost-sharing for the Extraction of erupted tooth (D7210) provided November 1, 2020. 

Additionally, though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the Limited oral evaluation - problem focused (D0140) provided November 1, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for intra-operative monitoring services.

You asked the Plan to pay for intra-operative monitoring services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says they have not received a Centers for Medicare & Medicaid Services letter that you participate in Medicare.

Medicare rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment.

Payment cannot be made for items purchased from this provider because there is no documentation that this provider is enrolled in Medicare. Therefore, we decided that the Plan does not have to pay for intra-operative monitoring services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and pontic - porcelain/ceramic (D6245).

You asked the Plan to pay for the limited oral evaluation and pontic. You say that you do not believe your benefit has been exceeded. The Plan denied your request. The Plan says your benefit has been exhausted.

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 case record shows that the Plan already covered one limited oral evaluation in the year 2020. Additionally, the record shows that you met your annual maximum when the claim for the pontic processed. Once you reach your annual maximum you are responsible for any remaining charges. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and pontic - porcelain/ceramic (D6245).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal spacer placement (22870, 22869).

You asked the Plan to pre-approve the spinal spacer placement. You say that the service is medically necessary. The Plan denied your request. The Plan says the procedure is considered investigational and is not covered.

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 spinal spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the interspinous spacer has not been shown to be safe and effective in long term studies and there is a lack of evidence to support that the devices are as safe and effective as surgical decompression. 

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 spinal spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal spacer placement (22870, 22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554) to be provided by an out of network provider.

You asked the Plan to pre-approve the continuous glucose monitor. You say that the in-network vendor is too expensive and you would prefer the out-of-network provider. The Plan denied your request. The Plan says the items must be obtained from a network provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554) to be provided by an out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee has no complex wound care or other skilled nursing need. The documentation does not indicate that the enrollee's functional requires skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the optometry visit you had on September 24, 2020.

You asked the Plan to waive the copayment for the optometry visit. You say that you do not think you should have to pay for this because you believe it was only for a flu shot. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that this copayment is being applied to a claim for an optometry visit, not a flu shot.

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 $40 copayment for vision care. 

We looked at the records in your case. In your appeal, you appear to be disputing this charge because you believe this claim is in reference to a flu shot. That is not the case. This claim is in reference to an optometry visit you had on September 24, 2020. Records show that you received the flu shot on September 15, 2020. You have been asked to pay a $40 copayment for the optometry visit that occurred on September 24, 2020. The optometry visit 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 optometry visit you had on September 24, 2020. If you have questions about your concerns around your flu shot, please direct those inquiries to your Plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating hospital on September 2, 2020, to October 12, 2020.

You asked the Plan to waive the copayment for an injection. You say that this was done in an office. 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 $325 copayment for outpatient surgery/in-network/outpatient hospital. 

You have been asked to pay a $325 copayment for an injection. The total amount you are being asked to pay is $650 ($325 x 2 injections = $650). An injection falls within the outpatient surgery/in-network/outpatient hospital 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 outpatient surgery provided by a participating hospital on September 2, 2020, to October 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the abutment supported crown (D6061), the antimicrobial agents (D4381), and the unlisted preventive service (D1999) provided on October 15, 2020.

You asked the Plan to reimburse you for the dental services. You say that you were referred to this dentist because of a toothache. You say that the services were not covered. You say that you do not understand why it matters if the dentist is in network or not. You say that you needed these services. You also say that you have a $1,000 reimbursement plan and should be reimbursed for these services. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services that you receive from a provider who has opted out of Medicare.

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, dental services that you receive from a provider who has opted out of Medicare will not be reimbursed. Therefore, we decided that the Plan does not have to reimburse you for the abutment supported crown (D6061), the antimicrobial agents (D4381), and the unlisted preventive service (D1999) provided on October 15, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for psychiatry services provided on November 9, 2020.

You asked the Plan to reimburse you for psychiatry services. You say that the Plan should reimburse you. The Plan denied your request. The Plan says this provider has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for psychiatry services provided on November 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit tie down accessory (K0108) for a power wheelchair.

You asked the Plan to pre-approve the tie down accessory. You say that the tie down is medically necessary. The Plan denied your request. The Plan says this item is for use outside the home and is not covered.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a transit tie down accessory (K0108) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) provided on January 5, 2021.

You asked the Plan to pay for the dental service. You say that this should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services are only covered when received by a participating 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, dental services are only covered when received by a participating provider. Therefore, we decided that the Plan does not have to pay for the extraction (D7140) provided on January 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Prolia injection for the enrollee.

You asked the Plan to pre-approve Prolia under Medicare Part B. You say that this drug is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that this was a request for Prolia (denosumab) syringe to be dispensed directly to the enrollee from the pharmacy. This is not covered under the Medicare Part B benefit.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve a Prolia injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for diagnostic tests and images and an injection provided by participating providers on August 2, 2019, to August 21, 2019.

You asked the Plan to waive the coinsurance for diagnostic tests and images and an injection. You say that you do not understand why you owe this much. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for outpatient diagnostic tests and Medicare Part B prescription drugs. 

You have been asked to pay a 20% coinsurance of the allowed amount for diagnostic tests and images and an injection. The total allowed amount is $917.83. The total amount you are being asked to pay is $183.56 ($917.83 x 20% = $183.56). Diagnostic tests and images fall within the outpatient diagnostic tests benefit category and an injection falls within the Medicare Part B prescription drugs 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 diagnostic tests and images and an injection provided by participating providers on August 2, 2019, to August 21, 2019.