Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the services provided. You say that the facility is responsible for obtaining authorization. The Plan denied your request. The Plan says services rendered by a non-contract provider requires 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 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 on March 19, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cataract surgery provided on February 5, 2021.
You asked the Plan to waive the copayment for the cataract surgery. You say that you do not agree with the copayment because your doctor insisted on doing the cataract surgery. 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 $195 copayment for each Medicare-covered outpatient hospital facility visit. You have been asked to pay a $195 copayment for the cataract surgery. The cataract surgery falls within the "Outpatient Surgery, including services provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows the cataract surgery was provided at an outpatient hospital.
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 cataract surgery provided on February 5, 2021.
Your complaint that your right eye is worse after the surgery 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation and follow-up visits (99215, 99205) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office consultation and follow-up visits. You say that your tremors have gotten worst over time and you can't hold anything in your hands. You also say that you have seen several neurologists with the Plan and they all just prescribe medicine. You would like to see a provider at an out-of-network facility with higher level of care. The Plan denied your request. The Plan says there are in-network providers available for these services.
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. The records provided for review do not
show that the services at issue are urgent or emergent. 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 an office
consultation and follow-up visits (99215, 99205) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the copayment for the inpatient hospital admission and services provided from April 8, 2021, to April 14, 2021.
You asked the Plan to waive or reduce the copayment for inpatient hospital care. You say that you normally do not have to pay this much. You say you cannot afford this bill as you live on a fixed income. The Plan denied your request. The Plan says the cost sharing for this claim was assessed 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 $275 copayment for each of the first six days of an inpatient hospital stay. There is no copayment for days after the sixth day.
You have been asked to pay a $1,650 copayment for inpatient hospital care. You were in the hospital for six days and discharged on a seventh day. ($275 x 6 = $1,650). 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 or reduce the copayment for the inpatient hospital admission and services provided from April 8, 2021, to April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve collection and application of autologous blood concentrate product (D7921).

You asked the Plan to pre-approve the dental service. You say that you need this service. The Plan denied your request. The Plan says collection and application of autologous blood concentrate product is not listed as a covered service.

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 collection and application of autologous blood concentrate product is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve collection and application of autologous blood concentrate product (D7921).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of the extremity veins (93970) rendered by
the OON provider on April 15, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without a 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the duplex scan of the extremity veins (93970) rendered by the OON provider on April
15, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoulder arthroscopy with rotator cuff repair, distal
claviculectomy, and decompression of subacromial space with partial acromioplasty.
You asked the Plan to pre-approve the requested shoulder surgery. You say that it is felt that this surgical
intervention is medically necessary at this time. The Plan denied your request. The Plan says there has not been
sufficient conservative care which is shown to have failed. Imaging does not demonstrate a full-thickness
rotator cuff tear nor do physical examination findings correlate with pathology that would warrant surgical
intervention.
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 requested shoulder surgery. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found this 67-year-old male was being treated for impingement syndrome of left
shoulder. He presented with bilateral shoulder pain. He notes several months of relief with the previous
injections on December 16, 2020. He has difficulties with pain in his bilateral shoulders. However, detailed
documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive
conservative care measures including any physical therapy or recent medications. In addition, there are no
current objective findings for the right shoulder. There is no compelling rationale presented or extenuating
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore,
the request for shoulder arthroscopy with rotator cuff repair, distal claviculectomy, and decompression of
subacromial space with partial acromioplasty 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 requested shoulder surgery have not been met. Therefore, we decided that
the Plan does not have to pre-approve shoulder arthroscopy with rotator cuff repair, distal claviculectomy, and
decompression of subacromial space with partial acromioplasty.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Bone marrow aspirate remains experimental for use in spinal surgery. More research is needed to show safety and efficacy of the bone marrow aspirate when used as bone grafting material. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a brain PET is covered when specific criteria are met. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is noted to have memory problems with behavioral disturbance. The records do not show that the enrollee meets the diagnostic criteria for Alzheimer's dementia and fronto-temporal dementia; therefore, the PET scan is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), an intraoral complete series of radiographic images (D0210), an extraction (D7210), drugs or medicaments dispensed in the office for home use (D9630), a cone beam computed tomography image (D0364), incomplete endodontic therapy (D3332), and fillings (D2391 x3) provided from February 9, 2021, through April 7, 2021.

You asked the Plan to pay for a comprehensive oral evaluation, an intraoral complete series of radiographic images, an extraction, drugs or medicaments dispensed in the office for home use, a cone beam computed tomography image, incomplete endodontic therapy, and fillings. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, an intraoral complete series of radiographic images, an extraction, drugs or medicaments dispensed in the office for home use, a cone beam computed tomography image, incomplete endodontic therapy, and fillings have not been met. Specifically, services were provided by an Opt Out provider. The Plan does not cover dental services when provided by an Opt Out provider. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), an intraoral complete series of radiographic images (D0210), an extraction (D7210), drugs or medicaments dispensed in the office for home use (D9630), a cone beam computed tomography image (D0364), incomplete
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture (D5213), and a lower partial denture (D5214).
You asked the Plan to pre-approve an upper partial denture, and a lower partial denture. You say that your current dentures are causing pain and you need replacements. The Plan denied your request. The Plan says the services are a covered benefit, but you have exceeded the frequency limit of one every 60 months.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an upper partial denture, and a lower partial denture have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on July 17, 2018. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213), and a lower partial denture (D5214).
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 you need additional, more intensive therapy to rebuild strength and endurance before being released to go home. The Plan denied your request. The Plan says the IRF level of care is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray provided on April 1, 2021, by an OON provider.
You asked the Plan to pay for the x-ray. You say that the service is medically necessary. The Plan denied your
request. The Plan says there is no coverage for a non-authorized service from a non-contracted provider.
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. The
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the x-ray provided on April 1, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay half for the bone replacement graft for ridge preservation
(D7953) provided on February 23, 2021.

You asked the Plan to pay half for the dental service. You say that you called and were advised that the plan
would pay half for the service as it was an emergency. You say that your health depended on the bone graft.
You also say that at least half of the service should be covered. The Plan denied your request. The Plan says the
bone replacement graft for ridge preservation is not listed as a covered service.

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 bone replacement graft for ridge
preservation is not among those covered under this benefit. Additionally, the record does not show that you
contacted the Plan regarding this service specifically, only about fillings and the optional supplemental dental
coverage. Therefore, we decided that the Plan does not have to pay half for the bone replacement graft for ridge
preservation (D7953) provided on February 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the enrollee has suffered with lumbar spinal stenosis with worsening low back and bilateral lower extremity pain for the past decade. You state the condition results in the narrowing of the spine causing cramping, pain, tingling and weakness in the back, buttocks and legs which limits their daily activities. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with spinal stenosis. The record indicates that imaging has demonstrated moderate to severe spinal stenosis at L3-L4 and L4-L5, the levels requested for treatment. The elements of the coverage criteria are not 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the pelvis you had on May 6, 2021.

You asked the Plan to waive the copayment for the MRI. You say that you have had MRIs at other hospitals in the past and have never received a bill. The Plan denied your request. The Plan says you were charged this copayment 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 $275 copayment for diagnostic radiology services. 

You have been asked to pay a $275 copayment for the MRI. The MRI falls within the diagnostic radiology 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 magnetic resonance imaging (MRI) of the pelvis you had on May 6, 2021.