Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary. Transfer to a lower level of care may be considered when treatment has completed. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care.
Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in
this case. Our physician reviewer found the records show that the enrollee was medically stable and had been
provided medical clearance to undergo the procedure. There were no factors documented in the records to
suggest this enrollee would likely have complications or require hospital services that would cross 2 midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite of three surfaces (D2393) provided on March 1, 2021.
You asked the Plan to pay for the resin-based composite. You say that you have coverage for periodontal services once every 6 months. The Plan denied your request. The Plan says the resin-based composite (D2393) denied processing at the alternate benefit of an amalgam (D2160). You are responsible for the 20% coinsurance plus the difference between the allowed amounts.
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, white multi-surface fillings on back teeth will be processed as a silver filling (amalgam) and you are responsible up to the contracted fee. You must pay a 20% coinsurance of the allowed amount ($150) for the amalgam, which is $30, plus the difference between the allowed amount of the resin-based composite ($198) and the amalgam ($150), which is $48. Therefore, we decided that the Plan does not have to pay for the resin-based composite of three surfaces (D2393) provided on March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the deluxe frames (V2025) and sphere, single vision lenses
(V2100) provided December 31, 2020.
You asked the Plan to pay for the deluxe frames and single vision lenses. You say that you expected your
eyeglasses to be covered since they are similar to the glasses you purchased the previous year. The Plan denied
your request. The Plan says you purchased eyeglasses from an out-of-network provider and therefore they are
not eligible for coverage.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services up to a $250 allowance when rendered by a provider in the Plan's
third-party vision vendor's network.
We looked at the file and the Plan's rules. The eyeglasses in this case were purchased from a provider who is
not part of the vision network. Based on this information, we decided that the Plan's rules for coverage of the
deluxe frames and single vision lenses have not been met. Therefore, we decided that the Plan does not have to
pay for the deluxe frames (V2025) and sphere, single vision lenses (V2100) provided December 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for breathing therapy visits provided on January 6, 2021, January 21, 2021, and January 28, 2021.
You asked the Plan to pay for the therapeutic procedures (97112). You say that your sleep is improving greatly from the breathing therapy. The Plan denied your request. The Plan says the rendering provider is not a Medicare provider
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy when performed by a licensed professional therapist. We looked at the file and Medicare rules. The provider is a certified orofacial mycologist. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedures (97112) have not been met. Therefore, we decided that the Plan does not have to pay for breathing therapy visits provided on January 6, 2021, January 21, 2021, and January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the hearing aids (V5261) provided February 4, 2021.
You asked the Plan to provide additional payment for the hearing aids. You say that the hearing aids should be covered The Plan denied your request. The Plan says the maximum hearing aid allowance has been applied to the claim and you are responsible for the remaining amount.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids up to a $1,000 allowance. We looked at the file and the Plan's rules. The Plan provided documentation showing the hearing aids have been covered up to the $1,000 allowance. Based on this information, we decided that the Plan does not have to provide additional payment for the hearing aids (V5261) provided February 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment is experimental/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 a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has lumbar back pain with neurogenic claudication from multi-level disease. Imaging demonstrates severe spinal stenosis at the requested L1-L2 procedure level. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
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 the enrollee will benefit from acute rehab to optimize her level of functioning prior to returning home. The Plan denied your request. The Plan says the enrollee does not need an intensive team for 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 in the Medicare rules section. 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 the enrollee was admitted to the acute hospital for non-surgical management of a subdural hematoma, gluteal hematoma, fractured ribs and fractured clavicle after a fall. Her medical conditions are stable. There are no complex nursing needs. She does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory work provided on February 19, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for the laboratory work provided on February 19, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (x-ray) (D0330),
periapical first radiographic image (x-ray) (D0220), and periapical additional radiographic images (D0230)
provided on February 17, 2021.

You asked the Plan to pay for the panoramic and periapical x-rays. You say that the services should be covered.
The Plan denied your request. The Plan says these services are not covered benefits.

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
panoramic radiographic image (x-ray) (D0330), periapical first radiographic image (x-ray) (D0220), and
periapical additional radiographic images (D0230) provided on February 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nasal endoscopy provided on March 17, 2020.

You asked the Plan to waive the copayment for the nasal endoscopy. You say that you were never aware of any charges for the procedure. You say you are unable to pay this amount. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a $150 copayment for the nasal endoscopy. The nasal endoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows the procedure was performed in an outpatient setting.

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 nasal endoscopy provided on March 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220)
and the intraoral - periapical each additional radiographic image (D0230) received October 15, 2020.

You asked the Plan to pay for the intraoral periapical radiographic images (D0220, D0230). You say that the
dental provider performed the wrong kind of x-rays and you do not want to pay for their mistake. The Plan
denied your request. The Plan says the provider billed for procedure codes D0220 and D0230. These codes are
not covered under your supplemental 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 pay for the
intraoral - periapical first radiographic image (D0220) and the intraoral - periapical each additional
radiographic image (D0230) received October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Botox injection provided on February 26, 2021.

You asked the Plan to waive the coinsurance for the Botox injection. You say that the Botox injection is medically necessary to treat your migraines. You say you cannot afford this treatment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for in-network Medicare-covered Part B prescription drugs.

You have been asked to pay $242.52 which is 20% of the allowed amount for the Botox injection. The allowed amount is $1,212.61. ($1,212.61 x 20% = $242.52). The Botox injection falls 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 Botox injection provided on February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3330), problem focused limited oral evaluation (D0140), and first intraoral periapical x-ray (D0220) provided on March 23, 2021, and March 30, 2021.

You asked the Plan to pay for the endodontic therapy, problem focused limited oral evaluation, and first intraoral periapical x-ray. You say that you thought the root canal was covered, and should be paid. The Plan denied your request. The Plan says the endodontic therapy is not a covered service.

The Plan also says that both the problem focused limited oral evaluation and first intraoral periapical x-ray are covered once per calendar year.

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, endodontic therapy (D3330) is not among those covered under this benefit. The contract says that problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) are each limited to once per calendar year. The record shows that you received a problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) which were paid by the Plan on January 13, 2021, and your problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the endodontic therapy (D3330), problem focused limited oral evaluation (D0140), and first intraoral periapical x-ray (D0220) provided on March 23, 2021, and March 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on a breast reduction (19318) provided by a Certified Surgical First Assistant (CSFA) on October 22, 2020.

You asked the Plan to pay for surgical assistant services. You say that this service is supported in the records. The Plan denied your request. The Plan says this is no covered for the type of provider that performed the service.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services on a breast reduction (19318) provided by a Certified Surgical First Assistant (CSFA) on October 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete denture (D5110), provided on February 1, 2021.

You asked the Plan to pay for the complete denture. You say that the service should be covered. The Plan denied your request. The Plan says the service is not covered under the enrollee's plan benefits.

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 complete denture (D5110), provided on February 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ArthroFlex procedure (17999).

You asked the Plan to pre-approve an ArthroFlex procedure. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment is experimental/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 an ArthroFlex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that ArthroFlex remains experimental for complete rotator cuff tears. More literature is needed to show the safety and efficacy of ArthroFlex for rotator cuff tear repair.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an ArthroFlex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an ArthroFlex procedure (17999).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient (99347) rendered by the out of network (OON) provider on August 21, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient (99347) rendered by the out of network (OON) provider on August 21, 2020.