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

We decided that the Plan does not have to pay for acupuncture services (97814, 97813) provided on August 20, 2020.
You asked the Plan to pay for acupuncture services. You say that you were told this would be covered. The Plan denied your request. The Plan says this is not covered for the type of provider at issue.
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. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the record shows that the services were provided by a licensed acupuncturist rather than a physician licensed to perform the service. Therefore, we decided that the Plan does not have to pay for acupuncture services (97814, 97813) provided on August 20, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member cannot participate in intensive therapy and does not meet criteria for inpatient rehabilitation services.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a stroke. The
enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's care could be given at a lower level.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral tissue biopsy (D7286, D9239, D9243).
You asked the Plan to pre-approve the oral tissue biopsy. You say that the oral tissue biopsy is medically necessary. The Plan denied your request. The Plan says this service is not covered under your dental 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 an oral tissue biopsy (D7286, D9239, D9243).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance transportation services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON ambulance transportation services. You say that the clinical documentation provided supports the need for the requested services. The Plan denied your request. The Plan says there are in-network ambulance services that are available for your care.
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 OON services. Therefore, we decided that the Plan does not have to pre-approve ambulance transportation services 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are 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. 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the injections rendered on December 22, 2020 to January 12, 2021.
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 procedure codes J2001 (lidocaine injection) and J7321 (Hyalgan injection) do not match the NDC number.
The Plan must follow Medicare rules. The rules say that all drugs, including Prodrugs, are reported to DME MACs by National Drug Code (NDC). We looked at the file and Medicare rules. The file shows that the drug services were not billed with the correct 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 injections rendered on December 22, 2020 to January 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an observation stay and an MRI provided from January 19, 2021, to January 20, 2021.
You asked the Plan to waive the copayments for an observation stay and an MRI. You say that you disagree with the charges because you were inpatient and should only owe a $260 copayment. 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 $300 copayment for outpatient hospital observation. Your contract with the Plan also clearly says that you must pay
a $200 copayment for MRI's. The medical records show that you had an observation stay from January 19, 2021, to January 20, 2021. Therefore, you are responsible to pay the $300 copayment. The medical records show that you received an MRI during an outpatient hospital stay from January 19, 2021, to January 20, 2021. Therefore, you are responsible to pay the total allowed amount of $175.89, which is less than the $200 copayment. The total amount you owe is: $475.89. You have been asked to pay the total copayment amount of $475.89 for an observation stay and an MRI. An observation stay falls within the outpatient hospital observation benefit category. An MRI falls 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 copayments for an observation stay and an MRI provided from January 19, 2021, to January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites provided on January 12,
2021 by an OON provider.
You asked the Plan to pay for the resin-based composites. You say that you were not advised that this provider
was not in-network. The Plan denied your request. The Plan says these services were rendered by a noncontracted
provider. The Plan also says that no benefits are available for procedures performed by OON
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the two
resin-based composites provided on January 12, 2021 by an OON provider.
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 September 22, 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 September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 10, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you feel that you should not owe a copayment for the services because you did not see a specific physician on the billing claim. 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 $50 copayment for specialist visits. The medical records show that you received specialist services on December 10, 2020. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on December 9, 2020.
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says the hearing aids purchased were not covered devices under the Plan's copayment structure. You must choose a device that is included on the hearing aid formulary.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid 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. The file shows that the hearing aids provided were not included on the Plan's hearing aid formulary. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on December 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve resin-based fillings (D2393, D2394, D2332, D2391) for teeth #13, #14, #4 and #6.

You asked the Plan to pre-approve the fillings. You say that these services are necessary. The Plan denied your request. The Plan says the enrollee has already had fillings on the requested teeth and surfaces within the last three years. Only one filling may be provided per surface per tooth every three years.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan can cover one amalgam, composite or resin filling per surface per tooth every three years.

Though the Plan offers a dental benefit in excess of Medicare coverage, the fillings are requested in a frequency that is not covered under this benefit. Documentation shows that the Plan paid for fillings on the requested teeth and surfaces on March 8, 2021, August 5, 2020, and July 7, 2020. Therefore, we decided that the Plan does not have to pre-approve resin-based fillings (D2393, D2394, D2332, D2391) for teeth #13, #14, #4 and #6.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and the filling (D2391) provided November 16, 2020, to December 7, 2020.
You asked the Plan to reimburse you for the dental services. You say that you have been going to the same dentist for years. You say that the Plan has always reimbursed your 50%. You also say that this office has never been in the Medicare network. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot be made for dental services performed by a provider who has opted out of Medicare.
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 the services could be covered, dental services performed by a provider who has opted out of Medicare cannot be reimbursed. Therefore, we decided that the Plan does not have to reimburse you for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and the filling (D2391) provided November 16, 2020, to December 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Novolog.

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 drug is not eligible for a tier exception.

The Plan must follow Medicare rules. Medicare rules say that Part B drugs are not eligible for a Part D tier exception. 

We looked at the file and Medicare rules. Novolog is a Part B covered drug and not eligible for a Part D tier exception. 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 tier exception for Novolog.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional periapical x-ray (D0230) provided on February 8, 2021.
You asked the Plan to pay for the additional periapical x-ray. You say that you went to the dentist for an assessment on what treatment you would need for your severe dental problems. You also say that you are not financially able to cover the dental services needed to regain your health. The Plan denied your request. The Plan says 2 x-rays per calendar year are covered. The Plan also says that the frequency limit has been exceeded.
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 periapical x-rays are listed as covered, the frequency limit has been reached. The record shows that the Plan paid for the bitewing x-ray (D0274) and the initial periapical x-ray that you received on February 8, 2021. Therefore, we decided that the Plan does not have to pay for the additional periapical x-ray (D0230) provided on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided on August 18, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not provided by a physician.
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. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the services were not provided by a physician, nor under the supervision of a physician. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided on August 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve semi electric hospital bed (E0295) Bed side rails, half
length (E0305) mattress innerspring (E0271).
You asked the Plan to pre-approve the hospital bed. You say that you need the hospital bed due to a previous
hip operation. You have gag reflexes at night and feel as if you're choking. You also had heart surgery a month
ago for a pacemaker and struggles sleeping on that side. The Plan denied your request. The Plan says the
records do not show that the enrollee meets the criteria listed for the hospital bed.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 hospital bed. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the documentation does not support that the enrollee has a condition that requires frequent changes in body position and there is no indication that he requires a semi-electric bed for bed mobility. 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 hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve semi electric hospital bed (E0295) Bed side rails, half length (E0305) mattress innerspring (E0271).