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

We decided that the Plan does not have to pay for the oral exam (D0120), the periodontal maintenance (D4910), and the nitrous oxide (D9230) provided on December 1, 2020.

You asked the Plan to pay for the dental services. You say that your dentist advised that you need more than the normal amount of periodontal service. The Plan denied your request. The Plan says that the frequency limit for oral exams has been exceeded. The Plan says periodontal maintenance is not listed as a covered service. The Plan also says that nitrous oxide is not listed as a covered 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 periodontal maintenance and nitrous oxide are not among those covered under this benefit. Additionally, the frequency limit of 2 oral exams per year has been exceeded. The record shows that the Plan paid for oral exams that you received on Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), the periodontal maintenance (D4910), and the nitrous oxide (D9230) provided on December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CPAP supplies provided from March 20, 2020, to September 20, 2020.

You asked the Plan to waive the coinsurance for the CPAP supplies. You say that you were not told that you would have a 20% coinsurance for renting the device. The Plan denied your request. The Plan says you have been charged 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 advanced durable medical equipment and all other durable medical equipment and supplies. You have been asked to pay a total of $74.77 for the CPAP supplies. The CPAP supplies 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 CPAP devices and supplies provided from March 20, 2020, to September 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for two units of therapeutic exercises (97110) and one unit of
neuromuscular reeducation (97112) provided on August 20, 2020.

You asked the Plan to pay for therapeutic exercises and neuromuscular reeducation. You say that these services
are supported in the records. The Plan denied your request. The Plan says the billed units are not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units
provided for each procedure code. For any single timed CPT code in the same day measured in fifteen-minute
units, providers bill a single fifteen-minute unit for treatment greater than or equal to eight minutes through and
including 22 minutes. If the duration of a single modality or procedure in a day is greater than or equal to 23
minutes, through and including 37 minutes, then two units should be billed.

We find that two units of CPT code 97110 and one unit of CPT code 97112 are not supported in the medical
record. The medical record only supports one unit of CPT code 97110, as it only documents fifteen minutes of
service. No units of 97112 are supported as the record does not document the time spent on this service. Based
on this information, we decided that Medicare rules for coverage of therapeutic exercises and neuromuscular
reeducation have not been met. Therefore, we decided that the Plan does not have to pay for two units of
therapeutic exercises (97110) and one unit of neuromuscular reeducation (97112) provided on August 20,
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of a sacral nerve neurostimulator for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of a successful trial of sacral nerve neurostimulator.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of a successful trial of a sacral nerve neurostimulator. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement through test stimulation. Improvement is measured through voiding diaries. In addition, the stimulation period should last one week, and in this case, only lasted 2 days. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of a sacral nerve neurostimulator for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you will benefit from inpatient rehab that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says you do not require an intensive, complex, multidisciplinary approach to daily therapy.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

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 physician reviewer found that you were admitted to the acute hospital for surgical repair of a hip fracture after a fall. Your medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing needs. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 11, 2019 by an out of network (OON) provider.

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 were rendered by an out-of-network provider without 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 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 the medical services provided on October 11, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from October 9, 2019, to October 10, 2020.

You asked the Plan to waive the copayment for the emergency room visit. You say that you are appealing this claim. The Plan denied your request. The Plan says you have been charged 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 $120 copayment for emergency services provided at an in-network emergency room. 

You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit 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 the emergency room visit provided from October 9, 2019, to October 10, 2020.
Appeal type: ER
Decision: Partially Favorable

You asked the Plan to waive the copayment for emergency care surgery service and CT scan. You say that you never went to surgery and should not have to pay this amount. The Plan says that the copayment amounts you are being charged are correct.

We decided that the Plan has to waive the copayment for emergency care surgery service.

The Plan follows Medicare rules. 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 says that you must pay $90 copayment for each covered emergency room visit. However, if advanced imaging services are received as part of an emergency department evaluation then you will only pay the advanced imaging copayment, not the emergency room copayment.

The Plan says that you must pay the $325 copayment outpatient surgery copayment. The surgery service you received was performed during the course of your emergency room visit. The records do not show that the surgery service was performed separately from the emergency care service, or that this service was not needed to evaluate or stabilize your emergency medical condition. You also received a CT scan during this emergency room visit, so you cannot be asked to pay the emergency room copayment for this visit. Therefore, you cannot be asked to pay any copayment for emergency care beyond the advanced imaging copayment you have already been asked to pay (which will be described in the next section). Therefore, we decided that the Plan has to waive the copayment for emergency care. 

We also decided that the Plan does not have to waive the copayment for CT scan.

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 $225 copayment for in-network advanced imaging, including CT scans. Therefore, we decided that the Plan does not have to waive the copayment for CT scan.

Therefore, we decided that the Plan has to reduce your total cost-sharing obligation for this claim from $550 to $225 copayment.

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 pay for the maxillary partial denture provided on November 5, 2020.

You asked the Plan to pay for the maxillary partial denture. You say that you lost your previous partial. The Plan denied your request. The Plan says the replacement of a lost or stolen denture 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 pay for the maxillary partial denture provided on November 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on November 10, 2020.

You asked the Plan to waive the copayment for an ultrasound. You say that you were told that you would not owe a 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 $50 copayment for each ultrasound. 

You have been asked to pay a $50 copayment for an ultrasound. An ultrasound 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 copayment for an ultrasound provided on November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit (99211) provided December 4, 2020.

You asked the Plan to waive the copayment for the urgent care visit. You say that you were unable to obtain testing at the Plan's preferred clinic. The Plan denied your request. The Plan says that testing is provided at the preferred clinic and the copayment 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 $25 copayment for Urgently needed services. 

You have been asked to pay $22.47 for the urgent care visit. This service falls within the Urgently needed 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 the urgent care visit (99211) provided December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Nucala injection (J2182) provided February 11, 2011.

You asked the Plan to waive the coinsurance for the Nucala injection. You say that you have not been charged for the injection in the past. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for coinsurance for Medicare Part B prescription drugs rendered at a Primary Care Provider (PCP)'s Office; Specialist's Office and Pharmacy. 

You have been asked to pay a total of $585.80 for the Nucala injection ($2,929 allowed amount x 20% coinsurance). Nucala injections fall within the Medicare Part B prescription drugs 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 Nucala injection (J2182) provided February 11, 2011.

Your complaint about a representative of the Plan potentially providing you with misinformation about the cost of the injection 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hospital visit (99281) provided on November 19, 2020.

You asked the Plan to waive the copayment for the hospital visit. You say that you went in for a COVID-19 test, met with a provider while still in your vehicle, and left when you were told you were ineligible. Because the meeting was so brief and care could not be provided, you do not believe you should be responsible for this payment. The Plan denied your request. The Plan says outpatient hospital observation services require a $50 copayment.

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 outpatient hospital observation. 

You have been asked to pay a $50 copayment for the hospital visit. Outpatient hospital observation services are given to determine if you need to be admitted or if care can be provided. You met with a provider at the hospital and were given an evaluation to see if you met criteria for the requested care. Therefore, the hospital visit falls within the outpatient hospital observation 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 the hospital visit (99281) provided on November 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the group 2 power wheelchair, batteries, and power seat
tilt (E2363, E1002, K0837).

You asked the Plan to pre-approve the group 2 power wheelchair and accessories. You say that this equipment
is medically necessary for the enrollee's medical condition. The Plan denied your request. The Plan says the
member resides in a skilled nursing facility and durable medical equipment is not covered in this living
situation.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.

Records show that the group 2 power wheelchair and accessories is being requested for use in a SNF or
hospital. Therefore, we decided that the Plan does not have to pre-approve the group 2 power wheelchair,
batteries, and power seat tilt (E2363, E1002, K0837).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an all lower extremity prostheses, flex-walk system or equal (L5981) and an all lower extremity prostheses, multi-axial rotation unit ('mcp' or equal) (L5986) for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the request for K3 foot does not meet Medicare criteria as 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 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The K3 advanced foot with rotational features is not medically necessary as the treating physician medical progress reports do not support that this patient's functional level meets the requirements for coverage of these items. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an all lower extremity prostheses, flex-walk system or equal (L5981) and an all lower extremity prostheses, multi-axial rotation unit ('mcp' or equal) (L5986) for the enrollee.
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 admission to an IRF is medically necessary. The Plan denied your request. The Plan says services could be obtained at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

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 there are no complex nursing or rehabilitation needs nor do you require an intensive rehabilitation program. 

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. Specifically, the services you require could be obtained at a lower level of care. This means that admission to an IRF is not medically necessary or reasonable. 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 pre-approve Oxycodone Tab.

You asked the Plan to pre-approve Oxycodone Tab. You say that you want the enrollee treated with this drug.
The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B
benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycodone Tab.

Benefits for Oxycodone Tab may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.