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

We decided that the Plan has to waive the copayment for visions services provided by a participating provider on November 12, 2020.
You asked the Plan to waive the copayment for visions services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says that the correct copayment has been applied.
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 has failed to send in a 2020 Evidence of Coverage. We find that because of this a decision cannot be rendered. Therefore, we decided that the Plan has to waive the copayment for visions services provided by a participating provider on November 12, 2020.
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 reimburse you for the crown (D2740) for tooth # 19 provided on March 30, 2021.
You asked the Plan to reimburse you for the dental service. You say that the crown was necessary. You say that you needed this crown to save your tooth and prevent the future need for dentures. You also say that you should be reimbursed for this service. The Plan denied your request. The Plan says the crown is not listed as a covered service. The Plan also says there is no record that contacted the Plan prior to the date of service to verify benefits and provider eligibility.
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 crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the crown (D2740) for tooth # 19 provided on March 30, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from March 20, 2021, to April 6, 2021.

You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says there were no daily skilled service needs.

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 pay for SNF services. Our physician reviewer found that the enrollee's stay in a SNF was not reasonable or medically necessary during this time period. There were no documented daily skilled nursing needs. At her level of function, she did not require skilled therapy services in an inpatient setting. 

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 pay for skilled nursing facility (SNF) services provided from March 20, 2021, to April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a
participating provider on December 16, 2020.
You asked the Plan to waive the copayment for a specialist office visit. You say that your copayment should
only be $35. The Plan denied your request. The Plan says the correct copayment 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 $45
copayment for physician/practitioner services/in-network/specialist.
You have been asked to pay a $45 copayment for a specialist office visit. The correct copayment has been
applied to the services that were provided. A specialist office visit falls within the physician/practitioner
services/in-network/specialist 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
office visit provided by a participating provider on December 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs provided from December 10, 2020, to December 11, 2020.
You asked the Plan to pay for the provided services. You say that the services should be covered. The Plan denied your request. The Plan says the provided services are not covered under your plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The drugs provided while receiving outpatient services are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the drugs provided from December 10, 2020, to December 11, 2020.
Benefits for the provided services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning provided on October 22, 2020.

You asked the Plan to pay for the cleanings. You say that marketing material does not clarify a maximum allowance. The Plan denied your request. The Plan says your financial responsibility is correct.

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.

We looked at the file, and Medicare rules. The file shows you received a dental cleaning from an out-of-network provider. The plan paid the allowed amount for the service provided. You were charged the difference between the billed amount and the allowed amount. Your plan contract says that for services covered under the plan, you may still be billed by an out-of-network provider for any amount greater than the maximum allowable charge made by the plan to the provider.

Based on this information, we decided that the Plan's rules for coverage of the cleanings have not been met. Therefore, we decided that the Plan does not have to pay for the dental cleaning provided on October 22, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam for a new patient (92004) and ophthalmic biometry (92136) provided on October 22, 2020.
You asked the Plan to pay for the vision care. You say that the services were necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the eye exam for a new patient (92004) and ophthalmic biometry (92136) provided on October 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 2) provided on March 11,
2020.

You asked the Plan to pay for the dental services. You say that your current dental plan covers periodontal
maintenance at 100%. The Plan denied your request. The Plan says although periodontal maintenance is
covered by the plan, gingival irrigation is not the same procedure as periodontal maintenance and is excluded
from coverage The Plan says that gingival irrigation is not listed as a covered service. The Plan also says that
the treatment plan from the provider does note that there would be no insurance payment for the service, and
you would be liable for the costs.

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 gingival irrigation are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival
irrigation (D4921 x 2) provided on March 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from January 11,
2021, through April 29, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the enrollee should not be
responsible for the charges. The Plan denied your request. The Plan says the copayments were 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $50 copayment per day, for days 1-3, and a $0 copayment per day, for days 4-90 for inpatient
hospital care. The inpatient cost share will begin on day one each time you are admitted or transferred to a
specific facility type.
The enrollee has been asked to pay a $300 copayment for inpatient hospital care. $150.00 copay applied each 2
claims for different date of service. The services at issue fall within the inpatient hospital care benefit category.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for inpatient hospital care from January 11, 2021,
through April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomics panel testing provided on January 26, 2021.
You asked the Plan to pay for the testing services. You say that the services in question were medically necessary. The Plan denied your request. The Plan says the testing was not ordered or approved by the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that diagnostic tests must be ordered by the physician who is treating the enrollee. We looked at the file and the rules. The case file shows that the physician listed on the requisition did not order the gene panel. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomics panel testing provided on January 26, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve capsule endoscopy (CPT code 91110 x1), for the enrollee.

You asked the Plan to pre-approve the endoscopy. You say that you are requesting that the enrollee undergo capsule endoscopy to rule out small bowel pathology. You state that the enrollee has anemia with unclear etiology, with history of gastric ulcer, which is now resolved, and with recent hemoglobin level of 9.7. You also state the enrollee had an esophagogastroduodenoscopy (EGD) on March 8, 2021. The Plan denied your request. The Plan says the service is not medically necessary for the enrollee's condition.

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 endoscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee likely has anemia of chronic disease, in large part secondary to their stage IV (4) renal disease. There is no provided documentation of ongoing gastrointestinal (GI) hemorrhage. The March 31, 2020, and July 1, 2020, complete blood count (CBC) reports elevated mean corpuscular volume (MCV). This, together with elevated ferritin is inconsistent with the iron deficiency that would otherwise be expected with ongoing GI bleeding. Prior to capsule endoscopy in evaluation of suspected small bowel hemorrhage, both EGD and colonoscopy should be negative for sites of GI bleeding. The criteria have not been met.

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 endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve capsule endoscopy (CPT code 91110 x1), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intracept spinal procedure (CPT code 22899), for the enrollee.
You asked the Plan to pre-approve the procedure. You say that the enrollee has tried and failed consecutive treatment without relief and this procedure would fill the current treatment gap for enrollees who do not have instability that requires a fusion and those who do not have adequate relief from conservative methods. 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 procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental. More research is needed to show safety and efficacy of the procedure for back pain treatment.
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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept spinal procedure (CPT code 22899), for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy (CPT code(s): 97802 and
97803).
You asked the Plan to pre-approve medical nutrition therapy. You say that the services are necessary. The Plan
denied your request. The Plan says the Medicare rules have not been met. The Plan must follow Medicare
rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of medical nutrition therapy have not been met. The medical information received with the request
does not indicate that you have a diagnosis of renal disease or diabetes mellitus. Based on the information
provided, you do not meet the Medicare criteria for medical nutrition therapy. Therefore, we decided that the
Plan does not have to pre-approve medical nutrition therapy (CPT code(s): 97802 and 97803).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic visit provided on April 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for chiropractic visit. You say that you see nothing on the Plan website showing that you needed a referral prior to this visit. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 a chiropractic visit provided on April 19, 2021 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on April 7, 2021 by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and paid. The
Plan denied your request. The Plan says prior authorization was not obtained for these services.
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 an office visit provided on April 7, 2021 by an
out-of-network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the parenteral nutrition you received from January 1, 2020, to April 30, 2021.
You asked the Plan to waive the coinsurance for the parenteral nutrition. You say that in 2019, this was covered at 100%. You said that you inquired about your benefits and were told there would be no change in your cost sharing for this service for 2020 and 2021. You said had you known that there would be a cost, you would not have stayed on this insurance. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that there were no changes to your benefits for this service between 2019, 2020, and 2021. The Plan says that in 2019, you had met your out-of-pocket maximum, which is why you were not charged coinsurance for these services after August 13, 2019.
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 prosthetic devices and related supplies. You have been asked to pay 20% coinsurance for the parenteral nutrition. The parenteral nutrition falls within the prosthetic devices 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 parenteral nutrition you received from January 1, 2020, to April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for three (3) office visits (99213, 99214) provided on March 30, 2021, to May 19, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for office visits. You say that you were under the impression that an authorization had been approved for you to see this provider. The Plan denied your request. The Plan says there are in-network providers available for these services.
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. there are in-network providers available for these services. 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 three (3) office visits (99213, 99214) provided on March 30, 2021, to May 19, 2021, by an out-of-network (OON) provider.