Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health, and home physical therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for coronary artery bypass grafting and a urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. You not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Freestyle Libre 2 sensor provided January 4, 2021.
You asked the Plan to waive the coinsurance for the Freestyle Libre 2 sensor. You say that you believed that you would not be charged a coinsurance. The Plan denied your request. The Plan says the cost share has processed correctly and no reimbursement is due.
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 durable medical equipment. You have been asked to pay a total cost share of $21.54 for the Freestyle Libre 2 sensor ($108.77 allowed amount x 20% coinsurance). The Freestyle Libre 2 sensor falls within the durable medical equipment benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Freestyle Libre 2 sensor provided January 4, 2021.
Your complaint about potentially receiving incorrect information regarding the coinsurance is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364), treatment of root canal obstruction (D3331), and retreatment of previous root canal therapy (D3348) provided on March 13, 2020.
You asked the Plan to pay for the cone beam CT capture and interpretation, treatment of root canal obstruction, and retreatment of previous root canal therapy. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364), treatment of root canal obstruction (D3331), and retreatment of previous root canal therapy (D3348) provided on March 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an inversion table (E1399) purchased July 24, 2020.
You asked the Plan to pay for an inversion table. You say that you believed this item would be covered and would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this item does not qualify as durable medical equipment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for an inversion table (E1399) purchased July 24, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 test provided on July 3, 2020.
You asked the Plan to pay for the COVID-19 test. You say that you have no knowledge of enrollee coverage prior to the specimen's arrival at the laboratory. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the COVID-19 test provided on July 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 12, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that this item was medically necessary for the enrollee's condition. The Plan denied your request. The Plan says there was no evidence of an established relationship between the prescribing physician and the enrollee.
The Plan follows Medicare rules. Medicare rules say that a lumbar-sacral orthosis is subject to the criteria listed in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the lumbar-sacral orthosis. Our reviewer says that the requested item was not medically reasonable and necessary. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient
documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back. 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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral periapical x-rays (D0220, D0230) provided on December 10, 2020 by an out-of-network provider.
You asked the Plan to pay for the intraoral x-rays. You say that you understood that the Plan covered at least part of the cost for out-of-network services, but do not know why the Plan is refusing any payment for these x-rays. The Plan denied your request. The Plan says this type of x-ray is not covered by Medicare or by the Plan's mandatory supplemental dental benefit, regardless of who provides the services. The Plan offers an optional additional dental benefit that can cover these services for an additional premium, but you did not choose to enroll.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral periapical x-rays (D0220, D0230) provided on December 10, 2020 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the gynecological exam provided on November 1, 2019.

You asked the Plan to pay for the gynecological exam. You say that this service was billed incorrectly. The Plan denied your request. The Plan says you had an exam from this provider.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. The benefit was exhausted. Based on this information, we decided that the Plan's rules for coverage of the exam have not been met. Therefore, we decided that the Plan does not have to pay for the gynecological exam provided on November 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on December 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 services provided to the enrollee by an out-of-network provider on December 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the procedure is investigational and experimental.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found The Vertiflex procedure remains experimental. More research is needed to show safety and efficacy before this can be approved. 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b). The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay 20% coinsurance for Medicare Part B Prescription Drugs. You can find this information on page 71 of the Plan's 2020 Evidence of Coverage (EOC).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from November 13, 2020, to November 22, 2020.
You asked the Plan to waive the copayment for the SNF stay. You say that you had no control over being transferred to the facility. The Plan denied your request. The Plan says you have been asked to pay 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 $0 copayment for days 1 through 20 and a $178 copayment per day for days 21 to 100. You have been asked to pay a $1,780 copayment for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) 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 SNF stay provided from November 13, 2020, to November 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on November 2, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels, except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. Per L36358, the requested testing is non-covered. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), and bitewing x-rays (D0272) provided on December 11, 2020.
You asked the Plan to pay for the intraoral periapical x-rays and bitewing x-rays. You say that you would like these services to be covered. The Plan denied your request. The Plan says the first intraoral periapical x-ray and additional intraoral periapical x-ray are not covered benefits under your dental plan. The Plan also says that the bitewing x-rays exceed the frequency limitation in your benefit 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. Though the Plan offers a dental benefit in excess of Medicare coverage, first intraoral periapical x-ray (D0220) and each additional intraoral periapical x-ray (D0230) are not among those covered under this benefit. The contract says that bitewing x-rays (codes D0270, D0272, D0273, D0274, and D0277) are limited to one procedure per plan year. The record shows that you received bitewing x-rays (D0270) on May 18, 2020, and your bitewing x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), and bitewing x-rays (D0272) provided on December 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care (99223) provided November 24, 2020.
You asked the Plan to pay for the inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99223 is not supported in the medical record. Specifically, the diagnosis code billed is not valid as a primary diagnosis. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care (99223) provided November 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral periapical x-ray (D0220) provided on January 5, 2021.
You asked the Plan to pay for the intraoral x-ray. You say that these services were provided by an in-network dentist and the Plan helped you set up the appointment. The Plan denied your request. The Plan says they have agreed to cover the evaluation at the in-network rate; however, the intraoral x-ray is not covered by Medicare or the Plan's supplemental benefit, regardless of who provides it.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral periapical x-ray (D0220) provided on January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myRisk genetic testing for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says there is no history or current diagnosis of cancer.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the documentation does not show that the enrollee has a current or personal historic diagnosis of cancer associated with the BRCA mutation. The requested test cannot be recommended.
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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve myRisk genetic testing for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a breast prosthesis provided on October 15, 2020.
You asked the Plan to pay for the breast prosthesis. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for a breast prosthesis provided on October 15, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs and emergency room services provided October 18, 2020 to October 19, 2020.
You asked the Plan to pay for the self-administered drugs and emergency room services. You say that the drugs should be covered, and the emergency room copayment should be waived. The Plan denied your request. The Plan says self-administered drugs are not covered under the Part B medical benefit when provided in the outpatient setting. The correct copayment was applied for the Emergency Room visit.
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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for the Emergency Room visit. 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. Additionally, self-administered drugs are not eligible for coverage under the Part B medical benefit in the outpatient setting. Therefore, we decided that the Plan does not have to pay for self-administered drugs and emergency room services provided October 18, 2020 to October 19, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.