Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on January 16, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the drug testing. You say that the service was medically necessary. 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 drug testing provided on January 16, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and
pneumatic appliance (E0673) provided on December 28, 2020.

You asked the Plan to pay for an intermittent limb compression device and pneumatic appliance. You say that
the requested item is a necessity for the care of the enrollee. The Plan denied your request. The Plan says
pneumatic compression devices are not covered by Medicare for the prevention of thrombotic events such as
deep venous thrombosis (DVT) or pulmonary embolisms (PE).

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically
necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with
venous stasis ulcers.

The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and pneumatic appliance (E0673) provided on December 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgery services provided on March 10, 2021.
You asked the Plan to waive the copayment for surgery services. You say that no operating room was involved and you should have any additional copayment. The Plan denied your request. The Plan says the correct cost-sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for surgery services provided at an in-network outpatient hospital. You have been asked to pay a $120.37 copayment for surgery services. Surgery services fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay less than or equal to 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 surgery services provided on March 10, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right upper eyelid surgery.

You asked the Plan to pre-approve the surgery. You say that delaying treatment until the right eye also qualifies will result in decreased quality of vision in the interim. The Plan denied your request. The Plan says attached frontal photographs shows that the right eyelid is far from obstructing the right pupil.

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 that in this case, the record indicates that the MRD is greater than 2 mm. The photographs provided do not indicate that the enrollee has a significant field restriction on the right. The elements of the coverage determination 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 right upper eyelid surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture, one or more needles, without electrical stimulation, each additional 15 minutes (97811) acupuncture, one or more needles, without electrical stimulation, initial 15 minutes (97810) infrared light therapy (97026) provided December 29, 2020.
You asked the Plan to pay for the office visit. You say that please review acupuncture medical records for payment. The Plan denied your request. The Plan says infrared therapy is a non-covered service. The provider is a non-covered provider type.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the health plan contract says that the person providing the acupuncture must be a physician licensed to perform the service. In this case, the provider is a licensed acupuncturist, not a physician. The records also do not document that this provider was supervised by any physician, PA, or NP/CNS. Therefore, we decided that the Plan does not have to pay for acupuncture, one or more needles, without electrical stimulation, each additional 15 minutes (97811) acupuncture, one or more needles, without electrical stimulation, initial 15 minutes (97810) infrared light therapy (97026) provided December 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee has acute closed compress fracture of L1 body after mechanical fall. You state the enrollee continues to have back pain and pain with movement. The Plan denied your request. The Plan says the stay 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of lumbar fracture after a fall. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by an out-of-network provider on June 19, 2020.
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you should not owe any more money for this. The Plan denied your request. The Plan says the correct coinsurance has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for durable medical equipment/out-of-network. You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The total allowed amount is $1,297.87. The total amount you are being asked to pay is $259.57 ($1,297.87 x 20% =
$259.57). The correct coinsurance has been applied to the equipment that was provided. Durable medical equipment falls within the durable medical equipment/out-of-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by an out-of-network provider on June 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion services rendered on October 28, 2020, to
November 24, 2020.

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 services are not covered.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be
exact duplicates of another claim or claim line are denied. The rules say that all drugs must be reported with a
valid NDC number.

We looked at the file and Medicare rules. The file shows that the claims for procedure codes 96366
(intravenous infusion, each additional hour) and 96365 (intravenous infusion, up to 1 hour) were previously
paid by the Plan on a separate claim for the same date of service. The file shows that the claims for procedure
code Q0163 (diphenhydramine hydrochloride, 50 mg, oral) were not billed with a valid NDC number. 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 infusion services rendered on October 28,
2020, to November 24, 2020.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for the home health services provided from May 20, 2020, to August 12,
2020, by an OON provider.

You asked the Plan to pay for the home health services. You say that there was a limited availability of other
home health service agencies during the onset of COVID-19. You also say that you accepted this enrollee in
good faith and performed reasonable and necessary care that was required. The Plan denied your request. The
Plan says that these services were rendered by an OON provider. The Plan also says that prior authorization
was not obtained.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not provide a copy of the applicable 2020 Evidence of Coverage
for this case. We asked for this document, but it was not provided to us. Without this information we cannot
determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been
adequately notified of the Plan's coverage rules and benefits. Consequently, the Plan has not substantiated their
denial of payment in this case. Therefore, we decided that the Plan has to pay for the home health services
provided from May 20, 2020, to August 12, 2020, by an OON provider.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a face bone graft (21210), augmentation of lower jaw bone (21127), interdental fixation (21110), adjacent tissue transfer or rearrangement (14040), diagnostic bone marrow aspirations (38220), and platelet rich plasma injection(s) (0232T).
You asked the Plan to pre-approve the face bone graft, augmentation of lower jaw bone, interdental fixation, adjacent tissue transfer or rearrangement, diagnostic bone marrow aspirations, and platelet rich plasma injection(s). You say that this treatment is medically necessary for the enrollee. The Plan denied your request. The Plan says routine dental care is not a Medicare benefit.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a face bone graft (21210), augmentation of lower jaw bone (21127), interdental fixation (21110), adjacent tissue transfer or rearrangement (14040), diagnostic bone marrow aspirations (38220), and platelet rich plasma injection(s) (0232T).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the arthrocentesis and injection provided on February 10, 2021.
You asked the Plan to waive the copayments for the arthrocentesis and injection. You say that COVID caused your medical condition. The Plan denied your request. The Plan says this appointment was scheduled before you had COVID and the specialist did not use a diagnosis code that would be for COVID.
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 $5 copayment for a Physician specialist visit, and 20% coinsurance for Medicare Part B drugs.
You have been asked to pay a $5 copayment for the arthrocentesis and 20% coinsurance for Medicare Part B drug. The arthrocentesis falls within the Physician specialist visit benefit category. The injection falls within the Medicare Part B drug 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 copayments for the arthrocentesis and injection provided on February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pulp cap - indirect (excluding final restoration) (D3120) for tooth 2.

You asked the Plan to pre-approve a deep medicated filling. You say that you would like the service covered. The Plan denied your request. The Plan says this service is not covered under your benefits.

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 pre-approve a pulp cap - indirect (excluding final restoration) (D3120) for tooth 2.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital clinic visit (G0463) and debridement services (97597) provided on February 10, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the clinic visit. You say that you are appealing this notification and requesting reconsideration of the denial. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for outpatient hospital clinic visit (G0463) and debridement services (97597) provided on February 10, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient hospital services provided from 
August 11, 2020, to October 15, 2020. 
 
You asked the Plan to waive the copayments for outpatient hospital services. You say that you were not aware 
that the charges would be so high. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct 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 $340 
copayment for outpatient hospital services.  
 
You received outpatient hospital services on August 11, 2020. Therefore, you are responsible to pay the 
allowed amount of $221.72, which is less than the $340 copayment.

You received outpatient hospital services on September 29, 2020. Therefore, you are responsible to pay the 
allowed amount of $240.80, which is less than the $340 copayment. 
 
You received outpatient hospital services on October 15, 2020. Therefore, you are responsible to pay the $340 
copayment. 
 
The total amount you owe is: $802.52. 
 
You have been asked to pay the total copayment amount of $802.52 for outpatient hospital services. Outpatient 
hospital services fall within the outpatient 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 copayments for outpatient hospital services provided from August 11, 2020, to October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5226).

You asked the Plan to pre-approve the dental service. You say that you did not receive dentures on the date of service in 2019. You also say that you only received a cleaning and x-rays on the date of service. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit has been reached.

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 partial lower denture is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a lower partial denture that you received on January 29, 2019. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2025) received on September 21, 2020.

You asked the Plan to pay for deluxe frames. You say that you would like the Plan to pay a portion of the item. You were told that eyeglasses were covered. The Plan denied your request. The Plan says there is no coverage for upgrades above standard frames and lenses.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of deluxe frames have not been met. Specifically, there is no coverage for upgrades above standard frames. Therefore, we decided that the Plan does not have to pay for deluxe frames (V2025) received on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 21, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 services provided by an out-of-network provider on February 21, 2020.