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

We decided that the Plan does not have to waive the coinsurance for the pacemaker insertion provided on September 17, 2019.
You asked the Plan to waive the coinsurance for the pacemaker insertion. You say that your doctor sent you to the hospital for surgery. You say that you thought this was an inpatient stay. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each outpatient hospital facility visit, including physician or surgical charges. You have been asked to pay $3,118.69, which is 20% of the allowed amount for the pacemaker insertion. The allowed amount is $15,593.45 (20% x $15,593.45 = 3,118.69). The pacemaker insertion falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical center" benefit category. The records show that this was an outpatient procedure. 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 pacemaker insertion provided on September 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on July 8, 2019.
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says the Plan requires
utilization of network providers when possible and available, and requires authorization for certain services. No
medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been
documented.
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 drug testing provided on July 8, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve porcelain crowns (D2740) for teeth # 8 and 9, and prefabricated post and core in addition to a crown (D2954) for teeth # 8 and 9.

You asked the Plan to pre-approve the dental services. You say that you cannot afford the requested services. You say that the crown is loose and cutting your mouth. You also say that you need 2 posts to help with the one that needs to be replaced. The Plan denied your request. The Plan says that crowns and the prefabricated post and core in addition to a crown are not covered services.

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 the dental services when the services are medically necessary and reasonable.

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 dental services. Our reviewer says that the requested dental services are medically necessary. Our reviewer found that the documentation provided indicates that the post and cores, and the crowns presently in place on teeth # 8 and 9 are defective and need replacement. Our reviewer found that the replacement of the defective post and cores, and the crowns on teeth # 8 and 9 is medically reasonable and necessary to restore these teeth to proper function.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to pre-approve porcelain crowns (D2740) for teeth # 8 and 9, and prefabricated post and core in addition to a crown (D2954) for teeth # 8 and 9. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for behavioral health services provided on November 14, 2018,
December 5, 2018 and December 20, 2018.
You asked the Plan to pay for the behavioral health services. 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 behavioral health services provided on November 14, 2018,
December 5, 2018 and December 20, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the SPECT test or the echocardiogram provided on September 20, 2019.
You asked the Plan to waive the coinsurance for the SPECT test and the echocardiogram. You say that you are appealing the $404.50 coinsurance. 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 outpatient hospital services. You have been asked to pay a total of $404.50 for the SPECT test and the echocardiogram. The SPECT test and the echocardiogram fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
September 20, 2019
SPECT test
$1,439.83
20%
$287.97
September 20, 2019
Echocardiogram
$582.65
20%
$116.53
Total
$404.50
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 SPECT test or the echocardiogram provided on September 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for bladder surgery provided on February 20, 2019.
You asked the Plan to waive the copayment for bladder surgery. You say that you switched plans. You say that you are appealing the payment for surgery. The Plan denied your request. The Plan says the copayment 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 $130 copayment for surgery services at an in-network outpatient hospital. You have been asked to pay a $130 copayment for bladder surgery. Bladder surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical center" 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 bladder surgery provided on February 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 25, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says services from an out-of-network provider requires 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 laboratory services provided on January 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the service is non-emergent and can be provided by an in-network provider.
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 pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services for a consultation and treatment to be provided by the physician.
You asked the Plan to pre-approve the physician's services. You say that you had a hip replacement provided by the physician in 2015 and you are having some clinical concerns with regard to your hip and you would like to see this physician since he performed the surgery. The Plan denied your request. The Plan says only emergent or urgent care can be covered with out-of-network providers.
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 pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services for a consultation and treatment to be provided by the physician.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two retainer crowns and a pontic.
You asked the Plan to pre-approve the bridge. You say that the enrollee was given the option of a bridge or a partial denture and he chose a bridge. You also say that the enrollee specifically selected his insurance so that it would cover a bridge. The Plan denied your request. The Plan says the notes sent in by the dentist do not explain why a removable denture cannot be used to replace the enrollee's missing teeth.
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 the bridge when the services are medically necessary and reasonable. 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 bridge. Our reviewer says that the service is not medically necessary. Our physician reviewer found since there was no documentation indicating that a removable prosthesis was contraindicated due to a physical or neurological condition, the criteria for a fixed bridge replacing tooth #6 has not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the bridge have not been met. Therefore, we decided that the Plan does not have to pre-approve two retainer crowns and a pontic.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a standard wheelchair.
You asked the Plan to provide a standard wheelchair. You say that the enrollee is short of breath and does not feel comfortable walking outside during the winter. The Plan denied your request. The Plan says criteria for a wheelchair have not been met.
The Plan follows Medicare rules. Medicare rules say that a wheelchair will not be covered if the enrollee does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker or cane, or the enrollee's home does not provide adequate access for use of the manual wheelchair. The file does not show if a walker or cane would meet the enrollee's needs, or the home would provide adequate access for the wheelchair. There is no documentation on the enrollee's upper extremity function. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to provide a standard wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by the out-of-network provider.
You asked the Plan to pre-approve a specialist office visit. You say that you would like to see the out-of-network provider because he did your original knee replacement surgery. 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 pre-approve 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 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 specialist office visit to be provided by the out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient mental health facility for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says less restrictive levels of care are available.
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 admission. Our reviewer says that
the requested admission is not medically reasonable or necessary. Our physician reviewer found there is no
documentation of the severity of illness. It is unclear if the enrollee would improve utilizing inpatient acute
hospitalization. There is a lack of inpatient records. There is no way to tell if active treatment is taking place.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to an inpatient mental health facility for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CT scan and the lumbar injection provided on October 4, 2019.
You asked the Plan to waive the coinsurance for the CT scan and lumbar injection. You say that you have no deductible for in-network services. You say that you want a refund. The Plan denied your request. The Plan says the coinsurance 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 25% coinsurance for advanced imaging services and surgery services at an in-network outpatient hospital.
You have been asked to pay a total of $256.95 for the CT scan and lumbar injection.
Service
Allowed Amount
Standard Coinsurance
Member Liability
CT Scan
$421.43
25%
$105.36
Lumbar Injection
$606.37
25%
$151.59
TOTAL:
$256.95
The CT scan and lumbar injection fall within the "Outpatient hospital 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 coinsurance for the CT scan and the lumbar injection provided on October 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the thyroid imaging and sodium iodide provided on October 22, 2019.
You asked the Plan to waive the coinsurance for the thyroid imaging and sodium iodide. You say that you were informed your copayment would not exceed $50. You say that you would not have had the test done if you knew. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered diagnostic imaging service and 20% coinsurance for Medicare-covered supplies.
You have been asked to pay a total of $155.44 for the thyroid imaging and sodium iodide.
Service
Allowed Amount
Standard Coinsurance
Member Liability
Thyroid Imaging
$238.08
20%
$47.62
Sodium Iodide
$539.08
20%
$107.80
TOTAL:
$155.44
The thyroid imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The sodium iodide falls within the "Outpatient hospital 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 coinsurance for the thyroid imaging and sodium iodide provided on October 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6539.
You asked the Plan to pre-approve the compression stockings. You say that you have vein problems. The Plan denied your request. The Plan says that gradient compression stockings are not covered in this setting.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6539 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6539.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves (E0667) for the enrollee.
You asked the Plan to pre-approve a pneumatic compression device and sleeves. You say that the use of Flexitouch is highly regarded amongst medical professionals. The Plan denied your request. The Plan says that your request is not reasonable and necessary according to Medicare and your Plan.
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 sleeves (E0667) for the enrollee.