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

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on February 10, 2020.
You asked the Plan to pay for the dental service. You say that you are being incorrectly billed for a full mouth periodontal maintenance procedure. You say that you only received periodontal maintenance for your lower jaw. You say that the provider intentionally schedules the service this way so that you have to pay out of pocket. You also say that this constitutes fraud. The Plan denied your request. The Plan says periodontal maintenance is covered once every 6 months. The Plan says the frequency limit has been reached. The Plan says they confirmed with the provider's office that you are only being billed for a copayment amount for the periodontal maintenance. The Plan also says they confirmed that you signed an agreement where you were advised of this arrangement and agreed to pay.
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 and periodontal maintenance is a covered service, the frequency limit of once every 6 months has been exceeded. However, the Plan confirmed with the provider's office that you are not being charged more than the previously agreed upon copayment amount. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on February 10, 2020.
Your complaint about the dentist scheduling services on a fraudulent basis 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hymovis (J7322). You asked the Plan to pre-approve Hymovis. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee has not met step therapy requirements.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 Hymovis. Our reviewer says that the criteria for coverage of Hymovis has not been met. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc first before they will approve the requested drug, Hymovis. The provided medical records do not indicate that the enrollee has tried the Plan's required drugs or that these drugs would likely be less effective or have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hymovis have not been met.Therefore, we decided that the Plan does not have to pre-approveHymovis (J7322).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99215) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that you are an established patient with this provider and do not want to have to switch to a new doctor. The Plan denied your request. The Plan says there are in-network providers that are able to provide this care. Therefore, coverage criteria has not been 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 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 an office visit (99215) to be 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 radiology services provided on October 1, 2019.
You asked the Plan to pay for the radiology services. 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 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 radiology services provided on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visits, diagnostic tests and medical
supply provided from October 7, 2019 through December 2, 2019.
You asked the Plan to waive the cost share for the office visits, diagnostic tests and medical supply. You say
that the Plan should cover most of the cost of the tests. You say that you are on a fixed income and will not be
able to get the treatments you need. The Plan denied your request. The Plan says the cost share 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 services obtained from an in-network specialist or under certain circumstances, treatment by a
nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's
office, a $100 copayment for each Medicare-covered radiological diagnostic service, not including x-rays from
an in-network provider, a $40 copayment for Medicare-covered non-radiological diagnostic services from an
in-network provider and 20% coinsurance for each Medicare-covered medical supply from an in-network
provider.
You have been asked to pay a total of $408.68 for the office visits, diagnostic tests and medical supply.
Date of Service Service Allowed Amount Standard Cost Member Liability
October 7, 2019 Office Visit $198.65 $40 $40
October 22, 2019 Echocardiography $193.78 $100 $100
October 23, 2019 Remote Cardiac
Monitoring $83.22
$40
$40
October 24, 2019 Stress Test $67.30 $40 $40
October 24, 2019 Medical Supply $243.40 20% $48.68
October 24, 2019 Myocardial
Perfusion Imaging $447.60
$100
$100
December 2, 2019 Office Visit $103.59 $40 $40
TOTAL: $408.68
The office visits fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit
category. The diagnostic tests and medical supply fall 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 cost share for the office
visits, diagnostic tests and medical supply provided from October 7, 2019 through December 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 17, 2019 to October 28, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says the care received could have been provided at an observation level of care, therefore coverage criteria for inpatient admission has not been met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found while the enrollee spent two midnights in the hospital, at the time of admission, it was not reasonable to expect that two midnights of inpatient level care would be medically necessary. While prolonged, the totality of the enrollee's care was consistent with observation level 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 acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided from October 17, 2019 to October 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214), partial upper denture (D5213), and resin-based composite fillings for teeth #21 and 29 (D2391). You asked the Plan to pre-approve a partial lower denture, partial upper denture, and resin-based composite fillings for teeth #21 and 29. You say that the requested items and services are necessary since you unable to eat properly.The Plan denied your request. The Plan says the covered benefit has been exhausted and partial dentures are not a covered benefit under your plan. Therefore, coverage criteria has not been met.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 or the benefit has been exhausted.Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214), partial upper denture (D5213), and resin-based composite fillings for teeth #21 and 29 (D2391).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 26, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that services furnished to a hospital inpatient must be billed with POS code 21.We looked at the file and Medicare rules. The file shows that the services were rendered while the enrollee was inpatient at a hospital and the claim was not billed with the required 21 POS code. 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 pay for the laboratory services rendered on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on January 20, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were not treated at the urgent care center and were told to go to the emergency room. You say you should not have been charged. The Plan denied your request. The Plan says you have been charged 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 $35 copayment for urgently needed services at an in-network urgent care center. You have been asked to pay a $35 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The record shows you were seen by the doctor.
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 urgent care visit provided by on January 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft ridge preservation (D7953) and
the periodontal scaling and root planing (D4341) for all 4 quadrants provided from October 23, 2019 to
November 4, 2019.
You asked the Plan to pay for the dental services. You say that the enrollee was given 2 different estimates for
cleanings. You say that the enrollee opted for the cleaning that was estimated at $525. You say that the
provider's office opened a Care Credit account in the enrollee's name without authorization for a total of the 2
estimates combined. The Plan denied your request. The Plan says the bone replacement graft for ridge
preservation and periodontal scaling and root planing are not listed as covered 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 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 bone
replacement graft ridge preservation (D7953) and the periodontal scaling and root planing (D4341) for all 4
quadrants provided from October 23, 2019 to November 4, 2019.
Your complaint about the enrollee being signed up for a Care Credit account without authorization 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 pay forpodiatry services provide on January 17, 2020 by an out of network (OON) provider.You asked the Plan to pay forpodiatry services. You say that you are in-network.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services were provided by an out-of-network 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 andpre-approved care.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 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 forpodiatry services provide on January 17, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on January 27, 2020.
You asked the Plan to waive the deductible for the office visit. You say that you were informed the doctor was in-network. You say that the claim should be paid as in-network. The Plan denied your request. The Plan says the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $500 for out-of-network services. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. The item or service you asked the Plan to waive the deductible for falls within "Physician/Practitioner services, including doctor's office visits" the benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $500 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on January 27, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on January 27, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight additional home health skilled nursing visits.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says skilled services can only be approved for a 60-day period.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 additional visits. Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. The urology clinic note reveals catheter changes are once a month. There are no extenuating reasons that would require 8 more SN visits in advance without ongoing assessment. You do not have other SN needs such as complex wound care. The criteria for 8 more SN visits at this time have not been met.
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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight additional home health skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair and a raised toilet seat.You asked the Plan to pre-approveashower chair and a raised toilet seat. You say that the raised toilet seat is needed because you do not have the ability to use the toilet in your apartment. It is a normal sized toilet and you say that you need an elevated seat so that you do not have tostruggle to sit down. You stated that the shower chair is needed so that you do not slip in the shower. You say that the equipment is needed for your safety.The Plan denied your request. The Plan says these items are not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs and raised toilet seats are not covered because they are not primarily medical in nature. While a shower chair and a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approvea shower chair and a raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Medtronic Guardian Sensor (A9278).
You asked the Plan to pre-approve a Medtronic Guardian Sensor. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Medtronic Guardian Sensor have not been met. Specifically, medical records were not provided. Without this documentation, medical necessity is not able to be established. Therefore, we decided that the Plan does not have to pre-approve a Medtronic Guardian Sensor (A9278).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to providenon-emergent ambulance transportation to a doctor appointment.You asked the Plan to providenon-emergentambulance transportation. You say that you cannot get to the curb and to your doctor appointments.The Plan denied your request. The Plan says there is no record of you being bedbound.The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to provide are ambulance transport services to a doctor's office.Therefore, we decided that the Plan does not have to providenon-emergent ambulance transportation to a doctor appointment.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee no longer needs PT services to be performed under the supervision of a licensed therapist.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. The file shows that 3 home health physical therapy visits were requested. The Plan has agreed to pre-approve 1 visit. 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 additional 2 visits. Our physician reviewer found that the enrollee is ambulating 100 feet without assistive device, and is at contact guard assist for transfers. She was instructed on a home exercise program (HEP). She had return demonstration and understanding, and the HEP was reviewed with correct performance. The records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the patient's condition, to establish/perform a maintenance program to maintain the enrollee's condition or prevent deterioration. The enrollee has had home exercise instruction and is at a functional level that does not require ongoing skilled physical therapy 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy services.