Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic testing supplies.
You asked the Plan to pre-approve the diabetic test strips. You say that the claim should be paid. The Plan denied your request. The Plan says there is a planned preferred alternative that must be attempted first.
Medicare rules say that plans can require enrollees to get DME from plan preferred providers. 'Contour Next Step' is not a plan preferred supplier. The requested provider in this case is not a preferred provider with the Plan. The Plan has preferred providers available who can provide the diabetic supplies 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 diabetic testing supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary.The Plan denied your request. The Plan says the enrollee can receive same services at the current level of care.

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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110), panoramic radiographic image (D0330), and topical application of fluoride varnish (D1206) provided August 6, 2020.
You asked the Plan to pay for the dental cleaning, x-rays and fluoride. You say that the services were necessary, and you cannot afford the cost. The Plan denied your request. The Plan says you did not have supplemental dental coverage at the time of the services and therefore they are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110), panoramic radiographic image (D0330), and topical application of fluoride varnish (D1206) provided August 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sildenafil.
You asked the Plan to pre-approve Sildenafil. You say that the medication is necessary. The Plan denied your
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Sildenafil.
Benefits for Sildenafil may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 10, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were medically necessary and reasonable. The Plan denied your request. The Plan says there was no established relationship between the prescribing physician and the enrollee.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeves are subject to the criteria listed 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 pay for the knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan provided on June 8, 2020.
You asked the Plan to waive the copayment for the duplex scan. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a duplex scan on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $100 copayment for Outpatient diagnostic tests. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a duplex scan on June 8, 2020 in an outpatient hospital facility. You have been asked to pay a $100 copayment for the duplex scan. The duplex scan falls within the Outpatient diagnostic tests 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 duplex scan provided on June 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cherry Bomb display shroud, Accu-Trac Motor technology, and power seat elevation feature for a power mobility device.

You asked the Plan to pre-approve display shroud, Accu-Trac, and power seat elevation feature. You say that these components are medically necessary to increase safety and decrease risk. The Plan denied your request. The Plan says the denial of authorization for these devices is correct, because these items are either excluded from coverage or are convenience items not needed for in-home use.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature.

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 display shroud, Accu-Trac, and power seat elevation feature. Our reviewer says that the requested display shroud and Accu-Trac feature are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested accessories exceed the enrollee's medical needs and are not necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of display shroud, Accu-Trac, and power seat elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a Cherry Bomb display shroud, Accu-Trac Motor technology, and power seat elevation feature for a power mobility device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 12, 2020.

You asked the Plan to pay for the physician's 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 physician's 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 physician's services provided on November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish provided on October 20, 2020.
You asked the Plan to pay for the topical application of fluoride varnish. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is 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. 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 topical application of fluoride varnish provided on October 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient clinic visit provided on January 11, 2021.

You asked the Plan to waive the copayment for the outpatient clinic visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient observation services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 $550 copayment for Outpatient Hospital Observation.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient clinic services provided to you on January 11, 2021. You have been asked to pay $106.32 copayment for the outpatient clinic visit, which is less than the contracted $550 copayment amount. The outpatient clinic visit falls within the Outpatient Hospital Observation 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 outpatient clinic visit provided on January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 31, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the laboratory 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 laboratory services provided on August 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided
from November 20, 2020, to November 21, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you feel you
should not be responsible for this cost share amount and you would like the Plan to reconsider your request.
The Plan denied your request. The Plan says you received inpatient hospital services on the dates of service at
issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $500
copayment per admission for Inpatient hospital services.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you had not met your
maximum out-of-pocket amount when the services at issue were provided. The file shows that you received
inpatient hospital services from November 20, 2020, to November 21, 2020. You have been asked to pay a
$500 copayment for the inpatient hospital services. The inpatient hospital services fall within the Inpatient
hospital 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 inpatient hospital
services provided from November 20, 2020, to November 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).

You asked the Plan to pre-approve a HFCWOD. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested device is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 

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 a HFCWOD. Our reviewer says that the documentation does not support that the enrollee meets criteria for the requested device. Our physician reviewer found the enrollee has diagnoses of asthma and bronchitis. The chest computerized tomography (CT) scan does not demonstrate bronchiectasis. The enrollee does not have cystic fibrosis. The records from 2021 indicate a new diagnosis of disorder of diaphragm. There are no radiographic or physical examination findings that support the new addition of this diagnosis. Therefore, the enrollee does not meet criteria for the requested device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a HFCWOD have not been met. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary, rest home visit provided on September 8, 2020.

You asked the Plan to pay for the physician's 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 domiciliary, rest home visit. 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 domiciliary, rest home visit provided on September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided September 14, 2020, and the resin-based composites (D2330, D2391) provided October 22, 2020.
You asked the Plan to pay for the scaling and resin-based composites. You say that you should have been told the cost of the services prior to receiving them. The Plan denied your request. The Plan says your $500 dental allowance has been paid and all additional costs are your responsibility.
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. In this case, the resin-based composites are a covered benefit under your plan. However, the Plan provided documentation that your annual maximum of $500 has already been met. Therefore, you are responsible for the cost of the services. Though the Plan offers a dental benefit in excess of Medicare coverage, scaling is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided September 14, 2020, and the resin-based composites (D2330, D2391) provided October 22, 2020.
Your complaint about potentially not receiving accurate and complete information about the cost of services from the provider prior to receiving them 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 waive the cost share for the electrocardiogram, the outpatient surgery services, and the specialist services provided from November 10, 2020 to November 18, 2020.

You asked the Plan to waive the cost share for the electrocardiogram, the outpatient surgery services and the specialist services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received an electrocardiogram, outpatient surgery services, and specialist services on the dates of service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan.

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 up to a copay maximum of $250 for Outpatient diagnostic tests, a $315 copayment for Outpatient surgery, and a $50 copayment for specialist services.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an electrocardiogram on November 10, 2020. You have been asked to pay a 20% coinsurance for the electrocardiogram, totaling $10.35. The electrocardiogram falls within the Outpatient diagnostic tests benefit category. 

The file shows that you received outpatient surgery services on November 18, 2020. You have been asked to pay a $315 copayment for the outpatient surgery services. The outpatient surgery services fall within the Outpatient surgery benefit category. 

The file shows that you received specialist physician services on November 17, 2020. You have been asked to pay a $50 copayment for the specialist physician services. The specialist physician services fall within the Physician/Practitioner services benefit category. 

This means that you have been asked to pay the correct amounts 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 electrocardiogram, the outpatient surgery services, and the specialist services provided from November 10, 2020 to November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay additionally for the outpatient hospital services provided on
October 15, 2020.
You asked the Plan to pay additionally for the outpatient hospital services. You say that you would like the
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says additional payment
cannot be made.
The Plan must follow Medicare rules. The rules say that revenue code 0272 is a packaged service for which no
separate payment is made. The cost for these services is included in the transitional outpatient payment and
outlier calculations.
The rules also say under the OPPS, packaged services are items and services that are considered to be an
integral part of another service that is paid under the OPPS. No separate payment is made for packaged services
because the cost of these items and services is included in the APC payment for the service of which they are
an integral part. In this case, the items and services with indicator N (Q4) are packaged into APC Rates 0255,
0272, 0300, 0301, 0305 and 0636. Therefore, we decided that the Plan does not have to pay additionally for the
outpatient hospital services provided on October 15, 2020.