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

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210), the local anesthesia not in conjunction with operative or surgical procedures (D9210) and the periodontal maintenance (D4910) received January 27, 2021.

You asked the Plan to pay for the dental services (D0210, D9210, D4910). You say that the plan should apply what it would normally cover for bitewing x-rays towards the complete series x-rays. The Plan denied your request. The Plan says the requested services are not covered under your supplemental 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 pay for the intraoral - complete series of radiographic images (D0210), the local anesthesia not in conjunction with operative or surgical procedures (D9210) and the periodontal maintenance (D4910) received January 27, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve cervical facet joint injection (CPT 64490) for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that there are multiple potential sources of pain.

The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 the injection. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the enrollee has postlaminectomy syndrome, diabetes with neuropathy, and Chiari malformation with tethered cord and arachnoiditis. The enrollee has primarily axial pain that has been present greater than three months. The enrollee has failed both conservative and operative treatment. The enrollee does not have radicular symptoms. The pain to be treated is not associated with other sources. The elements of the coverage rule are satisfied. 

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 injection have been met. Therefore, we decided that the Plan has to pre-approve cervical facet joint injection (CPT 64490) for the enrollee.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic casts (D0470) and occlusion analysis (D9950)
provided on January 4, 2021.

You asked the Plan to pay for the diagnostic casts and occlusion analysis. You say that you believe these
services should be covered. The Plan denied your request. The Plan says these services are not covered under
your 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
diagnostic casts (D0470) and occlusion analysis (D9950) provided on January 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the SNF care provided from October 1, 2020, to October 12, 2020.

You asked the Plan to waive the co-payment for SNF care. You say that you believe the enrollee should not be held liable. The Plan denied your request. The Plan says the co-payment amount the enrollee is being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 co-payment per day for days 1 to 20 and a $178 co-payment per day for days 21 to 100 for Skilled Nursing Facility (SNF) care. This SNF stay lasted 11 days, which were days 28 to 38 of the benefit period, resulting in a total co-payment amount of $1,958.

The enrollee has been asked to pay a $0 co-payment per day for days 1 to 20 and a $178 co-payment per day for days 21 to 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) 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 co-payment for the SNF care provided from October 1, 2020, to October 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on September 14, 2020.

You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says vision services must be received from a participating provider in order to be covered by the Plan.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine 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 from a participating provider.

We looked at the file and the Plan's rules. The file shows that they eyeglasses were not provided by a participating vision provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for the eyeglasses provided on September 14, 2020.
Appeal type: Lab
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 May 1, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are
available in-network.

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 May 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Acetaminophen and Oxycodone provided in an outpatient setting from January 5, 2021, to January 12, 2021.

You asked the Plan to pay for the Acetaminophen and Oxycodone. You say that these should be covered. You say that you had to have a stint put in. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Acetaminophen and Oxycodone provided in an outpatient setting from January 5, 2021, to January 12, 2021.

Benefits for the Acetaminophen and Oxycodone may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 10, 2020, by
an OON provider.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because the
lab rendered all tests ordered by the physician. The Plan denied your request. The Plan says utilization of
network providers is required when possible and available.

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 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 laboratory services provided on December 10,
2020, by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide or certified nurse assistant (S9122)
provided from September 2, 2019, to December 31, 2019.

You asked the Plan to pay for the home health aide or certified nurse assistant. You say that the enrollee needed
and qualified for these services. You also say that the enrollee is entitled to these services, and you believe they
should be covered. The Plan denied your request. The Plan says the services were obtained were rendered by a
provider who is not under contract with the Plan and is not certified for Medicare.

The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items
or services, a provider or supplier must be enrolled in the Medicare program.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the home health aide or certified nurse assistant have not been met. This provider is not part of the
Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for the home
health aide or certified nurse assistant (S9122) provided from September 2, 2019, to December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2391) provided on January 13, 2021.

You asked the Plan to pay for the dental service. You say that this should be covered. You say that you have only used $113.33 of the 2021 allowance for dental services. You say that you have always had coverage any type of dental service. You also say that this should be covered as there is money left in the allowance given. The Plan denied your request. The Plan says your dental coverage is limited to preventive services. The Plan says that the filling is not a preventive service. The Plan also says that the filling is not covered.

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 filling is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the filling (D2391) provided on January 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on July 20, 2020, to July 27, 2020.

You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with these copayments. The Plan denied your request. The Plan says the correct copayments have 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 $245 copayment for outpatient surgery/in-network/ambulatory surgical center visit. 

You have been asked to pay less than a $245 for each outpatient surgery. The total amount you are being asked to pay is $482.60 ($241.30 x 2 surgeries = $482.60). The correct copayments have been applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/in-network/ambulatory surgical center visit 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 provider on July 20, 2020, to July 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on December 28, 2020.

You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you were told that these services would be covered. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you made no contacts to the Plan prior to this date of service to verify benefits and provider eligibility.

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 problem focused limited oral evaluation and first intraoral periapical x-ray provided on December 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye drops you received on December 7, 2020.

You asked the Plan to pay for the eye drops. The Plan denied your request. The Plan says this is not medically necessary.

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 pay for the eye drops. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has dry eyes and keratoconus. The enrollee has not used anti-inflammatory eye drops or punctal plugs. The provided medical records do not provide a rationale why the standard of care therapies are not appropriate for the enrollee. The provided records do not support the medical necessity or reasonableness of the requested eye drops.

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 eye drops have not been met. Therefore, we decided that the Plan does not have to pay for the eye drops you received on December 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two replacement back wheels for a power wheelchair.

You asked the Plan to pre-approve the wheels. You say that this is medically necessary. The Plan denied your request. The Plan says you do not qualify for an electric wheelchair, so it would not be reasonable and necessary to replace the wheels.

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 wheels. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation notes that you have a mobility limitation. But, the documentation reveals that this limitation may be safely overcome by the use of crutches therefore a power wheelchair is not medically necessary and the power wheelchair back wheels E1399 would be considered not medically necessary. The request exceeds your medical 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 wheels have not been met. Therefore, we decided that the Plan does not have to pre-approve two replacement back wheels for a power wheelchair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from September 4, 2020, to September 30, 2020.

You asked the Plan to waive the copayment for SNF care. You say that you believe the enrollee should not be held liable. The Plan denied your request. The Plan says the copayment amount the enrollee is being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment per day for days 1 to 20 and a $178 copayment per day for days 21 to 100 for Skilled Nursing Facility (SNF) care. This SNF stay lasted 27 days, which were days 1 to 27 of the benefit period, resulting in a total copayment amount of $1,246. 

The enrollee has been asked to pay a $0 copayment per day for days 1 to 20 and a $178 copayment per day for days 21 to 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) 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 the SNF care provided from September 4, 2020, to September 30, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (99285) provided on September 1, 2020.

You asked the Plan to pay for the emergency room services. You say that you would like reconsideration because the member was seen multiple times in the same day. The Plan denied your request. The Plan says the submitted documentation supports 1 (one) unit of 99285, which was previously approved/paid.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We find that CPT code 99285 is not supported in the record. Specifically, the record only shows that one unit of CPT code 99285 was rendered on the billed date of service. There is insufficient documentation to verify the billed service. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services (99285) provided on September 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable control system, privacy flap, and side guards.

You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the enrollee does not need to operate the approved power options through the joystick.

The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered under certain medical indications.

The file shows that a privacy flap and side guards were requested. We looked at the file and the rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Based on this information, we decided that the Medicare rules for coverage have not been met.

The file also shows an expandable control system was requested. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested items. Our physician reviewer found that the enrollee has significant health concerns which include lymphedema, lower extremity edema, osteoarthritis, pain in lower extremities, polyneuropathy,and morbid obesity. She was approved for a Group 2 K0838 power wheelchair with power tilt and power elevating leg rests. The enrollee's function in the upper extremities, with the ability to get her mail, prepare a light meal or reheat her meals, indicates that she can control any power options through their own individual switches.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested items have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable control system, privacy flap, and side guards.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical nasopharyngoscopy with ballon dilation for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is the only FDA-approved procedure that can relieve Eustachian tube dysfunction. The Plan denied your request. The Plan says additional studies are needed to confirm that balloon sinus ostial dilation is safer and more effective over the long term than FESS or adenoidectomy.

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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the case file does not contain sufficient documentation of failure of medical management in the treatment of the enrollee's condition.

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical nasopharyngoscopy with balloon dilation for the enrollee.