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

We decided that the Plan does not have to pay more for the preventive procedure (D1999), maxillary partial denture (D5213), and mandibular partial denture (D5214) provided on January 20, 2021.

You asked the Plan to pay more for the preventive procedure, maxillary partial denture, and mandibular partial denture. You say that you spoke with a Plan representative who advised you that your 2021 benefits were the same as in 2020, and that you had a maximum of $2,000 that you were to receive for dental services in 2021. The Plan denied your request. The Plan says the Health Plan has issued payment to you for the Plan allotted amount and corrected the Health Plan error. The Plan also says that no further reimbursement is due to you by the Health Plan for dental services.

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 Plan offers a $2,000 allowance every year for non-Medicare covered preventive and comprehensive dental services combined. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit while processing this claim for the January 20, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the preventive procedure (D1999), maxillary partial denture (D5213), and mandibular partial denture (D5214) provided on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the vascular surgery consult to be provided by an OON provider.
You asked the Plan to pre-approve the vascular surgery consult. You say that the service was medically necessary. The Plan denied your request. The Plan says the provider is out-of-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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the vascular surgery consult to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Prolia injection and the laboratory work provided on November 19, 2020.
You asked the Plan to waive the cost share for the Prolia injection and the laboratory work. You say that you were told there would not be out of pocket expenses. 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 20% of the cost for Part B covered drugs and a $30 copayment for Medicare-covered laboratory services. You have been asked to pay $265.68 for the Prolia injection and the laboratory work. The Prolia injection falls within the "Medicare Part B prescription drugs" benefit category. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance/Copayment
Member Liability
November 19, 2020
Prolia injection
$1,261.43
20%
$252.29
November 19, 2020
Laboratory work
$13.39
$30
$13.39
Total
$265.68
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 cost share for the Prolia injection and the laboratory work provided on November 19, 2020
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chronic care management services (99490) provided on October 28, 2020.
You asked the Plan to pay for the chronic care management services. You say that this claim was denied for medical records. 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 chronic care management services (99490) provided on October 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ankle foot orthosis (L1951) and an addition to a lower extremity orthosis (L2820) to be rendered by the out of network (OON) provider.

You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are available in-network providers to render the requested items.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal. We found no exception that would require the Plan to pre-approve these items.

Therefore, we decided that the Plan does not have to pre-approve an ankle foot orthosis (L1951) and an addition to a lower extremity orthosis (L2820) to be rendered by the out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left total hip arthroplasty for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says surgical treatment should be a last option.
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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated for left hip pain; unilateral primary osteoarthritis, left hip. She noted on most recent exam that the cortisone injection in the left hip provided good relief. She notes the left hip is doing well. X-rays are noted to show severe degenerative joint disease. However, detailed documentation is not evident regarding a return of the left hip pain post-injection. There is documentation of improvement with both physical therapy and with cortisone injection. The appeal letter notes that she had benefit for 4-5 weeks and not 4-5 months; however, this is not demonstrated on provided medical documentation. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for left total hip arthroplasty is not medically reasonable or necessary.
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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a left total hip arthroplasty for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vest Airway Clearance System (E0483).
You asked the Plan to pre-approve a Vest Airway Clearance System. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for high frequency chest wall oscillation devices have not been met.
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a Vest Airway Clearance System (E0483).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis provided on February 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis. You say that you were advised by a Plan representative that the facility the treating provider works from was in-network with your plan. You also say that you were not advised that only certain dentists in that office are in-network. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that you were advised during your call with the Plan on January 29, 2021 that the treating provider is not in-network with 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis provided on February 23, 2021 by an out-of-network (OON) provider.
Your complaint about possibly being misinformed by the Plan 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0429, A0425) received February 11, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that you are on a fixed income and this copayment is an unexpected expense. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 $275 copayment for Ambulance Services. 

You have been asked to pay a $275 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services 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 ambulance transportation (A0429, A0425) received February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic visit, the MRI, and MR elastography provided on March 9, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient clinic visit, the abdominal MRI, and the MR elastography. You say that this appointment and procedure was medically necessary, and you were unaware a new referral was needed under this plan. The Plan denied your request. The Plan says no prior authorization was obtained.
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 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 outpatient clinic visit, the abdominal MRI, and the MR elastography provided on March 9, 2021 by an out of network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.

You asked the Plan to pre-approve the compression stockings. You say that the stockings are needed to help with your blood pressure and circulation in your legs. The Plan denied your request. The Plan says this item is not covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your request. The Plan says a trial of Zoledronic acid is required before alternatives like Prolia can be considered.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our reviewer says that Prolia is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drug or any reason the plan preferred drug would be unsafe or ineffective. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator provided from January 20, 2021, to March 20, 2021.

You asked the Plan to waive the coinsurance for the automatic external defibrillator. You say that you are appealing these claims. 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 20% of the total cost for Medicare-covered durable medical equipment and supplies.

You have been asked to pay 20% of the allowed amount for the automatic external defibrillator on each date of service. The allowed amount is $2,931.45. ($2,931.45 x 20% = $586.29). ($586.29 x 3 = $1,758.87). The automatic external defibrillator falls within the "Durable medical equipment (DME) and related 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 coinsurance for the automatic external defibrillator provided from January 20, 2021, to March 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided December 29, 2020.
You asked the Plan to provide additional payment for the tooth extractions. You say that the Plan's dental website did not indicate that the service would be subject to an allowed amount when provided out-of-network (OON). The Plan denied your request. The Plan says the cost sharing was assessed correctly based on OON rules.
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 Plan covers the tooth extractions with 50% coinsurance. If services are provided OON, the enrollee is responsible for the difference between the MAC and the total cost charged by the OON provider. We looked at the file and Medicare rules. The record shows that the Plan correctly covered 50% of the MAC for the service at issue. Based on this information, we decided that the Plan's rules for coverage of the tooth extractions have not been met. Therefore, we decided that the Plan does not have to provide additional payment for the extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided December 29, 2020.
Your complaint about the Plan's dental website potentially providing incomplete or confusing information 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

Explanation of decision
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) and the crown - porcelain fused to noble metal (D2752) received February 11, 2021.
You asked the Plan to pay for the core build up and crown. You say that you did not know there was a change to your coverage from 2020. The Plan denied your request. The Plan says there is no coverage for core buildup. The correct cost share applied to the crown.
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, core build up (D2950) is not among those covered under this benefit. The Plan agreed to reprocess the claim for the crown. The Plan's allowed amount for the crown is $633.42. You must pay 70% coinsurance for crowns. Your coinsurance for the crown
is $443.39. You have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) and the crown - porcelain fused to noble metal (D2752) received February 11, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on January 21, 2021.

You asked the Plan to pay for the physical therapy services. You say that The Plan denied your request. The
Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

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 physical therapy services. 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 physical therapy services provided on
January 21, 2021.
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving 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 the LTACH services have not been met. Specifically, the LTACH does not offer any medically necessary services for this enrollee that they are not already receiving at their current level of care. This means that admission into a LTACH is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.