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

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #29.
You asked the Plan to pre-approve the crown. You say that your dentist recommended you receive a new crown. The Plan denied your request. The Plan says crowns are only covered once every 7 years per tooth.
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, crowns are payable once in any seven-year period. The record shows that you received a crown on tooth #29 on August 3, 2020, and your crown benefit for tooth #29 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #29.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF admission provided from August 1, 2020, to August 17, 2020.
You asked the Plan to waive the copayment for the SNF admission. You say that you were not told you would have a copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment per day, days 1 to 20 and a $178 copayment per day, days 21 to 100 for each in-network SNF stay. You have been asked to pay a $1,892.96 copayment for the SNF admission. The SNF admission falls within the "Skilled nursing facility (SNF) care" benefit category. See chart below.
Dates of Service
Service
SNF Days
Copayment
Day Count
Member Liability
July 16, 2020 to July 31, 2020
SNF care
1-16
$0
16
$0
August 1, 2020 to August 4, 2020
SNF care
16-20
$0
4
$0
August 5, 2020 to August 17, 2020
SNF care
21-33
$178
13
$1,892.26 - This is less than the standard amount because you met your maximum out-of-pocket amount.
Total
$1,892.26
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 SNF admission provided from August 1, 2020, to August 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit and related services to be provided by a tertiary provider.
You asked the Plan to pre-approve the requested services. You say that you are still having rectal bleeding after your surgery. The Plan denied your request. The Plan says it would be reasonable to see a local surgeon.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that each medical group may make referrals to certain plan specialists and use certain hospitals within their network. We looked at the file and the rules. The medical records show that your condition is being treated with conservative measures. There is no indication that your condition requires a tertiary (higher) level of care.
We found no exception that would require the Plan to pre-approve the requested services. Therefore, we decided that the Plan does not have to pre-approve an office visit and related services to be provided by a tertiary provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp 60,000 units/per week twice a week.
You asked the Plan to pre-approve Aranesp 60,000 units/per week twice a week. You say that the requested dosage level is medically reasonable. The Plan denied your request. The Plan says the dosage twice a week is not medically necessary at this time.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Aranesp 60,000 units/per week twice a week. Our reviewer says that the requested twice weekly dosage is not medically reasonable and necessary. Our physician reviewer found that you are a 60-year-old female with pernicious anemia, iron-deficiency anemia, autoimmune hemolytic anemia, and low erythropoeitin. It was reported that Retacrit had not been working despite dose increase. Aranesp 60,000 units twice weekly was requested. In this case, the documentation does not support that the twice weekly dosage of Aranesp is medically reasonable or necessary. Based on the provided documentation, the primary cause of your uncontrolled anemia appears to be her autoimmune hemolytic anemia requiring focused treatment.
The documentation does not sufficiently support that the requested dosage of Aranesp is safe and effective considering you failed Retacrit and need additional treatment for your hemolytic anemia. The twice weekly dosing is not approved by the Federal Drug Administration for the conditions listed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp 60,000 units/per week twice a week have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp 60,000 units/per week twice a week.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet injections.
You asked the Plan to pre-approve facet joint injection. You say that the enrollee needs the injections for pain relief. The Plan denied your request. The Plan says the requested procedure is not supported with 3 months of moderate to severe neck or back pain and impaired function.
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 injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (64493) and injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) (64494). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee has radiculopathy and multiple non-facet causes of low back pain. The review has determined that the lumbar injections are not medically reasonable or necessary. The enrollee does not meet criteria for the requested procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (64493) and injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) (64494) have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the walker provided on February 5, 2021.
You asked the Plan to waive the coinsurance for the walker. You say that you had to pay for the equipment and then submit a claim to the Plan. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for out-of-network durable medical equipment. You have been asked to pay $15.63 which is 20% of the allowed amount for the walker. The allowed amount is $78.17. ($78.17 x 20% = $15.63). The walker falls within the "Durable medical equipment (DME) and related 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 coinsurance for the walker provided by on February 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care from June 30, 2021, forward.
You asked the Plan to pre-approve the continued inpatient mental health care. You say that inpatient mental health care is medically necessary. The Plan denied your request. The Plan says inpatient mental health care are no longer medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 continued inpatient mental health care. Our reviewer says that the criteria for continued inpatient mental health care have not been met. Our physician reviewer found that the enrollee is a 74-year-old male was admitted to the acute inpatient psychiatric hospitalization on June 11, 2021, with Major Neurocognitive Disorder with Behavioral Disturbance most likely due to Alzheimer's Disease. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. This patient was compliant with treatment and having no side effects to the medication. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. Based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of June 30, 2021, forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any aggressive behaviors being cooperative and compliant. 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 continued inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care from June 30, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218).
You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a fluid circulating cold pad with pump have not been met. Specifically, this is a non-covered service. Therefore, we decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 24, 2020.
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing facility care provided on April 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3/4 porcelain/ceramic crown (D2783) provided on October 29, 2020.

You asked the Plan to pay for the crown. You say that your provider advised that this service would be covered, but also that you had to pay $159. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that no contacts were made to the Plan prior to this date of service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The record shows that the provider confirmed they contacted your primary insurer, and you signed a treatment plan accepting responsibility for the cost of the services shown as not covered by the Plan. Therefore, we decided that the Plan does not have to pay for the 3/4 porcelain/ceramic crown (D2783) provided on October 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve topical application of fluoride varnish.
You asked the Plan to pre-approve the topical application of fluoride varnish. You say that you have very sensitive teeth and have discomfort. 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 pre-approve topical application of fluoride varnish.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transportation (A0427) provided on December 25, 2020.

You asked the Plan to waive the copayment for emergency ambulance transportation. You say that you were not aware that you would have to pay a co-payment. The Plan denied your request. The Plan says the co-payment was 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 $220 co-payment for ambulance services. 

You have been asked to pay a $220 co-payment for emergency ambulance transportation. The service at issue falls within the ambulance 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 emergency ambulance transportation (A0427) provided on December 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a medical eye exam (92012) provided on March 16, 2021.
You asked the Plan to waive the copayment for a medical eye exam. You say that you do not think it is a fair amount to charge as it is part of the complete process that you went in for. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $30 copayment for vision care.
You have been asked to pay a $30 copayment for a medical eye exam. The EOC confirms $30 is the required copayment for this service. A medical eye exam falls within the vision care 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 medical eye exam (92012) provided on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) and panoramic x-ray (D0330) provided on January 20, 2021.
You asked the Plan to pay for the consultation and panoramic x-ray. You say that the treating provider is in-network with your plan. The Plan denied your request. The Plan says the consultation is not a covered benefit under your dental plan. The Plan also says that the panoramic x-ray exceeds the frequency limitation in your benefit plan.
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, consultation (D9310) is not among those covered under this benefit. The contract says that panoramic x-ray (D0330) is limited to one procedure every three plan years. The record shows that you received a panoramic x-ray (D0330) on January 12, 2021 and your panoramic x-ray (D0330) benefit has been exhausted. Therefore, we decided that the Plan does not
have to pay for the consultation (D9310) and panoramic x-ray (D0330) provided on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 18, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you were unable to obtain authorization due to the short time period. You say services were 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 office visit provided on August 18, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested device. You say that The Plan denied your request. The Plan says a log was not provided showing insulin adjustments.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The medical records provided do not show that the enrollee uses insulin with at least three daily injections and requires frequent self-adjustment of insulin dosage based on the blood glucose testing results.
Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on December 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the domiciliary visit. You say that the hospital staff failed to obtain authorization and the doctor should not be penalized. You say the services were 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 domiciliary visit provided on December 24,
2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0481) provided to the enrollee on February 12, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0481 (1 Unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that HCPCS code G0481 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0481) provided to the enrollee on February 12, 2020.