Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay an additional $57 towards the denture. We decided that the Plan does not have to pay anything over the $750 maximum benefit.

You asked the Plan to pay an additional $57 towards the denture. You say that you do not have $1,438 to pay for the dental treatment. You say that you are on a very limited income. You say that paying this bill would be a financial hardship for you. You also say that you would like this bill to be paid. The Plan denied your request. The Plan says a maximum plan benefit coverage amount of $750 per year for covered preventive and comprehensive dental services. The Plan says that the maximum plan 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. The rules also say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

We decided that the Plan has to pay an additional $57 towards the denture.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We find that the Evidence of Coverage states there is a maximum plan benefit of $750 for covered dental services. The record shows that the Plan applied payment of $693 towards the denture. There is no documentation provided that substantiates the Plan's claim that the maximum plan benefit has been reached. Therefore, we decided that the Plan has to pay an additional $57 towards the denture.

We also decided that the Plan does not have to pay anything over the $750 maximum benefit.

Though the Plan offers a dental benefit in excess of Medicare coverage, the maximum plan benefit of $750 has been exhausted. The record shows that the Plan paid $693 towards this claim. With the additional $57 applied, the maximum benefit will be exhausted. The Evidence of Coverage clearly states that you are responsible for any cost above the $750 maximum. Therefore, we decided that the Plan does not have to pay anything over the $750 maximum benefit.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says predictive
screening testing is not a Medicare benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

The testing at issue was requested solely for screening purposes. Medicare does not cover this testing solely for
screening purposes. Therefore, we decided that the Plan does not have to pay for the lab testing services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on November 19, 2020.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you feel this service should be covered because you did not receive the first comprehensive oral evaluation. The Plan denied your request. The Plan says reimbursement for one comprehensive oral evaluation has already been issued.

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, comprehensive oral evaluation is limited to one procedure every three years. The record shows that you received a comprehensive oral evaluation on August 21, 2020 and your comprehensive oral evaluation benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses (V2307, V2750, V2799, V2797) provided July 17, 2020.

You asked the Plan to pay for the eyeglasses. You say that the eyeglasses should be covered in full. The Plan denied your request. The Plan says the plan only covers standard lenses and frames. The glasses provided include premium features that are not covered.

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 one pair of standard lenses and frames every two years. 

We looked at the file and the Plan's rules. The eyeglasses at issue featured non-standard features like transition and anti-reflective lenses, as well as upgraded frames. The plan only covers standard frames and lenses. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. The plan has already reimbursed for the cost of standard lenses and frames. Therefore, we decided that the Plan does not have to pay for eyeglasses (V2307, V2750, V2799, V2797) provided July 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider.

You asked the Plan to pay for the visit. 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 office visit provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Coolief ablation procedure of the left knee (CPT code 64624).

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says radiofrequency ablation (RFA) of peripheral nerves to treat pain (e.g., plantar fasciitis, occipital neuralgia, cervicogenic headache, osteoarthritis, etc.) including Coolief Cooled RFis considered experimental/investigational and is not a covered benefit.

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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found RFA of peripheral nerves for knee pain remains experimental. More research is needed to show the safety and efficacy of the procedure. Coolief ablation procedure should be denied. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve Coolief ablation procedure of the left knee (CPT code 64624).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of hot or cold packs (97010) provided on October 27, 2020.

You asked the Plan to pay for the application of hot or cold packs. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that status code B indicates that payment for covered services are always bundled into payment for other services not specified. 

We find that CPT code 97010 is not supported in the medical record. Specifically, this code has a status code of B. Payment for this service is bundled into the payment of other services. Based on this information, we decided that Medicare rules for coverage of the application of hot or cold packs have not been met. Therefore, we decided that the Plan does not have to pay for the application of hot or cold packs (97010) provided on October 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that your care needs can be provided at a lesser level of care.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall and for pulmonary fibrosis. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on November 5, 2020.

You asked the Plan to waive the coinsurance for an injection. You say that you cannot afford this coinsurance amount. 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 Medicare Part B prescription drugs/in-network. 

You have been asked to pay less than a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $2,414.76. Your 20% coinsurance is $482.95 ($2,414.76 x 20% = $482.95). You are being asked to pay $427.13. An injection falls within the Medicare Part B prescription drugs/in-network 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 an injection provided by a participating provider on November 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.

You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary for the enrollee. The Plan denied your request. The Plan says that the clinical value and effectiveness of Keytruda combined with MVASI in the setting of initial treatment of hepatocellular cancer have not been demonstrated in the peer-reviewed literature.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Keytruda. Our reviewer says that Keytruda is not medically reasonable and necessary for the enrollee. Keytruda is not FDA-approved for the enrollee's diagnosis as he has not received prior sorafenib. The use of Keytruda is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported, or not recommended in any of the compendia. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for Keytruda.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on September 14 and 16, 2020.

You asked the Plan to pay for the dental services. You say that you needed emergency dental services. The Plan denied your request. The Plan says services not listed are 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. 

The file shows that a core buildup (D2950), and unspecified procedures (D1999 and D2700) were provided. Although the Plan offers a dental benefit in excess of Medicare coverage, the services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on September 14 and 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth visits (99442) provided by an out of network (OON) provider.

You asked the Plan to pay for OON telehealth visits. You say that authorization was obtained but it processed incorrectly. The Plan denied your request. The Plan says these services were not authorized.

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 telehealth visits (99442) provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.

You asked the Plan to pre-approve proton beam therapy. You say that this is medically necessary. The Plan denied your request. The Plan says proton beam therapy is not the standard of care.

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 proton beam therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found while some may argue that it is standard practice to treat prostate cancer with proton therapy, both the American Society for Radiation Oncology (ASTRO) and the National Comprehensive Cancer Network (NCCN) guidelines recommend against routine use of proton therapy). 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Echo guide for biopsy (76942) provided on August 17, 2018, by an out of network (OON) provider.

You asked the Plan to pay for the Echo guide for biopsy. You say that the services should be covered. The Plan denied your request. The Plan says the services were provided without prior authorization and do not meet OON criteria for coverage.

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 Echo guide for biopsy (76942) provided on August 17, 2018, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided by an out-of-network provider on November 10, 2020.

You asked the Plan to pay for the lab 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 lab services provided by an out-of-network provider on November 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307, HCPCS G0483) provided to the enrollee on July 22, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.

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 80307 and HCPCS G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (CPT 80307, HCPCS G0483) provided to the enrollee on July 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. You say that it is not safe for you to return home. The Plan denied your request. The Plan says you do not require daily skilled nursing or therapy services.

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 services. Our physician reviewer found that you are at a supervision level with bed mobility, contact guard assist with transfers, and contact guard assist for ambulation with a walker. You do not require the skilled nursing services of a skilled professional nurse to provide treatment in a SNF. You have no complex wound care or other skilled nursing needs. You do not require skilled therapy services of a qualified therapy to provide treatment in a SNF. You do not require skilled nursing or therapy services on a daily basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the gastroenterologist office visit (99213) provided on October 15, 2020.

You asked the Plan to waive the copayment for the gastroenterologist office visit. You say that you were only seen by a nurse practitioner and should be charged a lower copayment. The Plan denied your request. The Plan says the copayment was 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). Your contract with the Plan clearly says that you must pay a $40 copayment for each specialist visit for Medicare-covered benefits. 

You have been asked to pay a $40 copayment for the gastroenterologist office visit. This service falls within the Physician/Practitioner services, including doctor's 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 the gastroenterologist office visit (99213) provided on October 15, 2020.