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

We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, five additional intraoral periapical x-rays, and non-autogenous connective tissue graft procedure provided on August 28, 2020, and October 29, 2020 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, intraoral periapical x-rays, and non-autogenous connective tissue graft procedure. You say that you were told that this provider was participating, and you would like these services to be covered. The Plan denied your request. The Plan says the treating provider is not a Medicare 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, the requested items or services are not covered when they are received OON. The record shows that when you contacted the Plan you were not advised that this provider was ever confirmed as a participating provider in the Plan's network. The record also shows that the Plan confirmed with the provider that you were advised prior to receiving the services that this provider does not accept any type of insurance. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, five additional intraoral periapical x-rays, and non-autogenous connective tissue graft procedure provided on August 28, 2020, and October 29, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the laboratory work provided on October 27, 2020.
You asked the Plan to waive the copayments for the laboratory work. You say that the removal of the lipoma was medical and not cosmetic. You say you were told the service was covered. 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 $5 copayment for in-Network Medicare-covered laboratory services. You have been asked to pay a $5 copayment for the laboratory work. The laboratory work falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the laboratory work provided on October 27, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay the out-of-network rate for the problem focused limited oral evaluation. We decided that the Plan does not have to pay in full for the problem focused limited oral evaluation.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this provider is listed as in-network on your explanation of benefits for this date of service. The Plan says that this service is not allowed because it was performed by a provider who has chosen to opt out of Medicare.
We decided that the Plan has to pay the out-of-network rate for the problem focused limited oral evaluation.
The Plan follows Medicare rules. Medicare rules say that an MA organization may make payment to a physician or practitioner described in paragraph (a) of this section for services that are not basic benefits but are provided to a beneficiary as a supplemental benefit consistent with 42 CFR section 422.102. The Plan says that you received these services from a Medicare opt out provider. There was no notice provided in the EOC that services with an opt out provider would not be covered for supplemental dental benefits. There was also no documentation provided that a private contract between you and the provider was signed. The contract does state that you are responsible for a 20% coinsurance for emergency diagnostic exams that are received out-of-network. You reasonably believed this service would be covered. Therefore, we decided that the Plan has to pay for the out-of-network rate for the problem focused limited oral evaluation.
We also decided that the Plan does not have to pay in full for the problem focused limited oral evaluation.
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 contract says that you must pay a 20% coinsurance when the emergency diagnostic exam is received out-of-network. The Plan does not have to pay more than an 80% coinsurance for this service. Therefore, we decided that the Plan does not have to pay in full for the problem focused limited oral evaluation.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery provided on November 18, 2020.
You asked the Plan to waive the copayment for outpatient surgery. You say that you cannot afford to pay this bill. The Plan denied your request. The Plan says the copayment amount you are 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). Your contract with the Plan clearly says that you must pay $300 copayment for outpatient surgery at an outpatient hospital. You have been asked to pay the allowed amount of $222.82, which is less than the $300 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery provided on November 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH criteria. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct.
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 receiving appropriate care at the current acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve coronary CT calcium scoring (75571).
You asked the Plan to pre-approve coronary CT calcium scoring. You say that the requested service is
medically necessary. The Plan denied your request. The Plan says that the requested service is a non-covered
screening service.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve coronary CT calcium scoring. Our
reviewer says that the requested service is medically necessary. Our physician reviewer found that the enrollee
has a history of hyperlipidemia but no known history of cardiovascular disease. The enrollee has an
intermediate 5 year cardiovascular risk of 7.8%. The enrollee can be considered for statin therapy at
intermediate dose based on this, though the enrollee has a history of intolerance to at least one statin and her
physician wanted to further risk-stratify her to assess the clinical importance of trying another statin given the
prior history of side effects. Coronary calcium scoring is recommended by guidelines to further refine the
enrollee's cardiovascular risk given the intermediate risk profile, especially with the prior issues with side
effects to the therapy. The CT calcium score would affect the long-term management of the enrollee's
hyperlipidemia. It would not be considered a screening test in this instance.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of coronary CT calcium scoring have been met. Therefore, we decided that the
Plan has to pre-approve coronary CT calcium scoring (75571).
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says while the member is a part of the Plan, they must use network providers to get their medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when the member is out of the area), out-of-area dialysis services and cases in which the plan authorizes use of out-of-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 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 to be provided by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive eye exam (92014) visual field examination (92083) provided October 5, 2020.

You asked the Plan to pay for the vision services. You say that the doctor is a participating provider and treated the enrollee for a medically necessary issue at the time of service. The Plan denied your request. The Plan says enrollee's must receive their services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when rendered by an in-network provider.

We looked at the file and the Plan's rules. Vision services must be rendered by an in-network provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for comprehensive eye exam (92014) visual field examination (92083) provided October 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The
Plan denied your request. The Plan says rules for LTACH care have not been met.
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 a 76-year-old female who initially presented to the acute care hospital
with confusion. There is no documentation provided necessitating admission to an LTACH. The enrollee is
receiving appropriate care at the present acute care hospital. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where she is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan.
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a primary care visit (99213) provided December 10, 2020.
You asked the Plan to waive the copayment for primary care visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct amount was 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 copayment for office visits. You have been asked to pay a $20 copayment for primary care visit. The primary care visit falls within the office visits 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 a primary care visit (99213) provided December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam (92012) provided by an out of network (OON) provider.
You asked the Plan to pay for the eye exam. You say that the provider should not have been required to obtain an authorization because the enrollee was admitted to a nursing home. The Plan denied your request. The Plan says criteria for obtaining out of network coverage was not met.
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 eye exam (92012) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan of extremity veins including responses to compression and other maneuvers provided on July 3, 2019.

You asked the Plan to pay for the duplex scan. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a duplex scan of extremity veins including responses to compression and other maneuvers provided on July 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard - hard appliance, full arch (D9944).
You asked the Plan to pay for the occlusal guard. You say that the requested item was necessary. The Plan denied your request. The Plan says the requested item is not covered under your supplemental dental 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 occlusal guard - hard appliance, full arch (D9944).
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 the Vertiflex procedure is medically
necessary. The Plan denied your request. The Plan says the device 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 device is experimental. More research is needed to show safety and
efficacy of the device. Open laminectomy is the gold standard procedure for lumbar spinal stenosis
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 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

We decided that the Plan does not have to pre-approve sacroplasty.
You asked the Plan to pre-approve sacroplasty. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan 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 sacroplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a sacral fracture. Sacroplasty remains experimental. More research is needed to show safety and efficacy of sacroplasty. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sacroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that this item is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Specifically, the requested medical records do not adequately support a diagnosis of diabetes. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine venipuncture, chest x-ray, comprehensive metabolic panel, measurement of lipase, complete blood cell count, therapeutic, prophylactic, or diagnostic injection, ED visit, and Ondansetron injection provided on January 31, 2020.
You asked the Plan to pay for the routine venipuncture, chest x-ray, comprehensive metabolic panel, measurement of lipase, complete blood cell count, therapeutic, prophylactic, or diagnostic injection, ED visit, and Ondansetron injection. You say that this claim has not been paid in full or under the terms of the contract for the services provided to this enrollee. 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 routine venipuncture, chest x-ray, comprehensive metabolic panel, measurement of lipase, complete blood cell count, therapeutic, prophylactic, or diagnostic injection, ED visit, and Ondansetron injection provided on January 31, 2020.