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

We decided that the Plan does not have to waive the copayment for laboratory services provided on April 15, 2021.

You asked the Plan to waive the copayment for laboratory services. You say that you feel that the claims are being processed incorrectly and this issue happened last year and was resolved. 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 $40 copayment for in-network and out-of-network laboratory services provided at an outpatient hospital facility. 

The medical records show that you received laboratory services at an out-of-network outpatient hospital facility on April 15, 2021. Therefore, you are responsible to pay the $40 copayment. 

You have been asked to pay a $40 copayment for laboratory services. Laboratory services fall within the laboratory 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 laboratory services provided on April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for hearing aids.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the services are not a covered benefit due to the provider being out-of-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral out-of-network for hearing aids.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete dentures - maxillary and mandibular (D5110, D5120).

You asked the Plan to pre-approve the services. You say that you need this as you do not have any teeth. The Plan denied your request. The Plan says this is covered once per five 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 covers dentures once every five years. 

Dentures were last received less than five years ago on April 30, 2019. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve complete dentures - maxillary and mandibular (D5110, D5120).
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 the enrollee is unable to ambulate without falling at home and would benefit from a SNF stay. The Plan denied your request. The Plan says that the enrollee has no complex needs and appears stable to receive services at a lower level of care.

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 osseous surgery, bone replacement, and guided tissue generation-resorbable barrier services.

You asked the Plan to pre-approve osseous surgery, bone replacement, and guided tissue generation-resorbable barrier services. You say that you have periodontal disease and are in need of these services. The Plan denied your request. The Plan says the requested services are not a covered benefit.

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 osseous surgery, bone replacement, and guided tissue generation-resorbable barrier services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device (22899, C9752).

You asked the Plan to pre-approve the Vertiflex Superion device. You say that because of his failure of conservative measures, the enrollee would make an excellent candidate for Vertiflex. The Plan denied your request. The Plan says the requested device is considered experimental. More research is needed to show safety and efficacy.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion device (22899, C9752).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete lower denture (D5120).

You asked the Plan to pre-approve the dental item. You say that the upper denture was approved. You say that you need lower dentures approved too. The Plan denied your request. The Plan says dentures are covered once every 60 months. The Plan says that they paid for a complete lower denture that you received on April 21, 2017. The Plan also says that you are not eligible for a replacement denture until 2022.

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 complete lower denture is listed as covered, the frequency limit has been reached. Therefore, we decided that the Plan does not have to pre-approve a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontic and retainer crown for a fixed bridge to replace tooth #5.

You asked the Plan to pre-approve the pontic and retainer crown. You say that your buccal health has deteriorated, and your tooth piece is not complete. You say that you are requesting an extraction of tooth #5 and a full bridge. The Plan denied your request. The Plan says the service is not medically necessary.

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, a fixed bridge is only covered for anterior teeth. Tooth #5 is not considered an anterior tooth. Therefore, we decided that the Plan does not have to pre-approve the pontic and retainer crown for a fixed bridge to replace tooth #5.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for glycosylated hemoglobin testing (83036) and a complete blood count (85025) provided on July 18, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for glycosylated hemoglobin testing and a complete blood count. You say that this was billed correctly. The Plan denied your request. The Plan says this was 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 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 glycosylated hemoglobin testing (83036) and a complete blood count (85025) provided on July 18, 2020 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on October 27, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for pathology services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network.

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 pathology services provided on October 27, 2020 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT
code 22869 and 22870), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the enrollee has suffered from this condition for
over five (5) years and has greatly impacted their quality of life. The Plan denied your request. The Plan says
the services are considered experimental and investigational.

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 items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the
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 the surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869 and 22870), for the
enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on February 2, 2021.

You asked the Plan to waive the copayment for emergency care. You say that why should you be charged for the emergency room visit when you cleared and drained your own bag. 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 $90 copayment for emergency care. 

The medical records show that you received emergency care on February 2, 2021. Therefore, you are responsible to pay the $90 copayment. 

You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided on February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and accessories (E0667).

You asked the Plan to pre-approve a pneumatic compression device and accessories. You say that the enrollee cannot use a basic device. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and accessories (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for durable medical equipment.

You asked the Plan to pre-approve the referral. You say that there is the presence of a heart assist device. The Plan denied your request. The Plan says there are no in-network inadequacies.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral out-of-network for durable medical equipment.
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 monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the information received does not meet the criteria, as only two doses of insulin are required per day.

The Plan must follow Medicare rules. The rules say that a continuous glucose monitor is covered if blood glucose is checked frequently per day (four or more times per day) and the insulin treatment regimen is frequently adjusted on the basis of testing results. 

The case file shows that blood sugars are checked twice a day in the morning and at bedtime. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Navage Saline Nasal Irrigation Kit (E1399).

You asked the Plan to pre-approve the Navage saline kit.. You say that you have a prescription from your ear, nose and throat doctor and you would like to appeal the denial. The Plan denied your request. The Plan says this item is a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve Navage Saline Nasal Irrigation Kit (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and dental cleaning (D1110) provided on February 22, 2021.

You asked the Plan to pay for the evaluation and cleaning. You say that you are supposed to get two cleanings and two exams in addition to your $1,000 limit for dental services. You had not had a cleaning or exam in 2021 prior to these services, and they should be covered. The Plan denied your request. The Plan says you have met your annual $1,000 limit for supplemental dental services, and additional services cannot be 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. The Plan will cover up to
$1,000 for routine dental services each year. You are responsible for any charges that remain after this benefit is exhausted.

Though the Plan offers a dental benefit in excess of Medicare coverage, routine dental care that exceeds the Plan's annual $1,000 limit is not covered under this benefit. The contract does not explicitly state that this limit only applies to comprehensive dental (as opposed to preventative dental) services and appears to apply to any services eligible for coverage under the supplemental dental benefit. Documentation shows that you have exceeded this $1,000 annual limit for dental coverage. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and dental cleaning (D1110) provided on February 22, 2021.

Your complaint about potential misinformation from a possible Plan representative 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for continued skilled nursing facility (SNF)
services beyond March 12, 2021 for the enrollee.
You asked the Plan to provide coverage for continued skilled nursing facility services. You say that continued
care is medically necessary as the enrollee is not comfortable living with her family member.
The Plan denied your request. The Plan says Medicare coverage criteria for SNF services were no longer met
as of March 10, 2021 and the enrollee was given notice that coverage would end on March 12, 2021. Maximus
overturned the Plans denial because a valid notice of non-coverage was not submitted with the case file. The
Plan requested a reopen and provided a copy of the notice signed on March 10, 2021.
The Plan is correct in this case. 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.
Based on the medical records provided, as of March 10, 2021, the enrollee's care was custodial in nature and
both the enrollee and the family member were being trained on continuing care and adapting to daily activities
at home for diabetic care and hygiene care. Medicare rules for coverage of continued skilled nursing facility
services were not met. Therefore, we decided that the Plan does not have to provide coverage for continued
skilled nursing facility (SNF) services beyond March 12, 2021 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on December 3, 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. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.

A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on December 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 8, 2021.

You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that the Guardant360 testing is not supported in the medical record. Specifically, laboratories should bill the code panel test code and not unbundle the individual components if all components of the code panel are performed. If a laboratory assays two or more genes in an enrollee in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. This means the services provided were billed incorrectly. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on March 8, 2021.