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

We decided that the Plan does not have to pay for the emergency exam (D0140) provided on October 28, 2020.

You asked the Plan to pay for the dental service. You say that you are not able to pay this bill. You say that you
are on a limited monthly income. You say that you had dental work done at this office which came loose later
that day. You also say that you had to return for a reseating of the same tooth. The Plan denied your request.
The Plan says 1 emergency exam is covered per 12-month period. The Plan also says that the frequency limit
has been exceeded.

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 emergency exam is listed as
covered, the frequency limit has been exceeded. The record shows that the Plan paid for an emergency exam
that you received on December 27, 2019. Therefore, we decided that the Plan does not have to pay for the
emergency exam (D0140) provided on October 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for MRI scan of lower spinal canal without contrast (CPT code 72148) provided on December 21, 2020.

You asked the Plan to waive the copayment for the MRI. You say that you think your copayment is too high for an MRI. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).

Review of the file show that you had MRI scan of lower spinal canal without contrast on December 21, 2020. You were asked to pay a $125 copayment for the MRI. Your 2020 EOC states, "enrollees must pay a $125 copayment for each Medicare-covered radiological diagnostic service, not including X-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). The diagnostic radiology services require specialized equipment beyond standard X-ray equipment and must be performed by specially trained or certified personnel. Examples include, but are not limited to, specialized scans, CT, SPECT, PET, MRI, MRA, nuclear studies, ultrasounds, diagnostic mammograms and interventional radiological procedures (myelogram, cystogram, angiogram, and barium studies)." 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 MRI scan of lower spinal canal without contrast (CPT code 72148) provided on December 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies in excess of the Medicaid allowed amount.

You asked the Plan to pre-approve an additional amount of incontinence supplies. You say that you need an additional amount of incontinence supplies. The Plan denied your request. The Plan says medical necessity is not established for incontinence products in excess of the allowable amount.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case Medicare does not offer coverage of these items. The Plan covers incontinence supplies however medical necessity has not been established for the excess amount requested. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies in excess of the Medicaid allowed amount.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ankle-foot orthosis (AFO) and shoe inserts.

You asked the Plan to pre-approve 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 an AFO is covered when specific criteria are met.

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 AFO is not medically necessary. Our physician reviewer found the enrollee has plantar fasciitis, heel spurs, and bursitis of both feet. The exams on March 18, 2021 and April 2, 2021 show intact reflexes and no focal or sensory deficits. There is no documented deformity, ligament laxity, or subluxation. There is no objective evidence on a physical exam that this enrollee has weakness or deformity of the foot and ankle that requires stabilization for medical reasons.

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.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.

The records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although shoe inserts may be appropriate, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition.

Therefore, we decided that the Plan does not have to pre-approve an ankle-foot orthosis (AFO) and shoe inserts.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit with an out-of-network provider.

You asked the Plan to pre-approve the office visit. You say that you previously received treatment with this
provider and this provider offers a superior knowledge and experience of the latest ophthalmic oncology
techniques. You say that a follow up visit with the in-network provider does not provide the same service. The
Plan denied your request. The Plan says in-network providers are available.

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
the office visit with an out-of-network provider.
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. The Plan denied your request. The Plan says the medical records
do not support the ability to tolerate an intensive rehab therapy program.

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 you are at a minimal assist level for sitting and standing up, and at contact guard assist for walking using a
rolling walker. You do not require the intensity of services provided at an IRF. Specifically, you are not shown
to require fifteen hours per week of rehabilitative services and regular physician evaluation.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for complete ultrasound of aorta, vena cava, groin vessels or bypass grafts (CPT code 93978) provided on November 6, 2020.

You asked the Plan to waive the copayment for the ultrasound. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file show that you had an ultrasound on November 6, 2020. The Medicare-allowed amount for the ultrasound is less than the set $155 copayment; therefore, you have been asked to pay the lesser amount of $147.40 for the ultrasound. 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 complete ultrasound of aorta, vena cava, groin vessels or bypass grafts (CPT code 93978) provided on November 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says this
service is considered experimental and not accepted for the proposed use.

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 requested services. Our physician
reviewer found that the interspinous spacer device is experimental. More research is needed to show its safety
and efficacy. Therefore, the requested service is not medically reasonable and necessary at this time.

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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve an interspinous spacer device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 13.

You asked the Plan to pre-approve the dental service. You say that the crown is medically necessary. The Plan denied your request. The Plan says porcelain crown 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 13.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sensors for a therapeutic CGM (K0553).

You asked the Plan to pre-approve CGM sensors. You say that the requested items are a necessity for you. The Plan denied your request. The Plan says rules for CGM sensors have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day or use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of CGM sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve sensors for a therapeutic CGM (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ultrasound of both sides of head and neck blood flow (CPT code 93880), ultrasound study of arm and leg arteries (CPT Code 93922), and complete ultrasound of aorta, vena cava, groin vessels or bypass grafts (CPT Code 93978 provided on October 7, 2020.

You asked the Plan to waive the copayment for the ultrasounds. You say that you thought the procedure would be under preventative care. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).

Review of the file show that you received three (3) ultrasounds on October 7, 2020. You were asked to pay a $135 copayment each for two (2) of the ultrasounds (CPT Code(s): 93880 and 93978). The Medicare-allowed amount for the ultrasound study of arm and leg arteries (CPT Code 93922) is less than the set $135 copayment; therefore, you have been asked to pay the lesser amount of $71.25 for this ultrasound. Your total cost share responsibility is $341.25 ($135 + $135 + $71.25 = $341.25). Your 2020 EOC states, "enrollees must pay a $135 copayment for each Medicare-covered radiological diagnostic service, not including X-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). The diagnostic radiology services require specialized equipment beyond standard X-ray equipment and must be performed by specially trained or certified personnel. Examples include, but are not limited to, specialized scans, CT, SPECT, PET, MRI, MRA, nuclear studies, ultrasounds, diagnostic mammograms and interventional radiological procedures (myelogram, cystogram, angiogram, and barium studies)." 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 ultrasound of both sides of head and neck blood flow (CPT code 93880), ultrasound study of arm and leg arteries (CPT Code 93922), and complete ultrasound of aorta, vena cava, groin vessels or bypass grafts (CPT Code 93978 provided on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ophthalmologist office visit (99204) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve an OON ophthalmologist office visit. You say that the enrollee does not have faith in the in-network providers. The Plan denied your request. The Plan says the requested service is available in-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 an ophthalmologist office visit (99204) to be provided by an out of network (OON) provider.
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 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 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 reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program.

While the medical record supports a need for physical and/or occupational therapy, there is no documented
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided in an IRF.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for removal of cataract with insertion of prosthetic lens (CPT code 66984) provided to the enrollee on July 30, 2020.

You asked the Plan to waive the deductible for the services. You say that you should only have a $198 deductible for 2020. The Plan denied your request. The Plan says the claim was processed accordingly with the enrollee's 2020 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Per the benefits outlined in the enrollee's 2020 EOC, the enrollee is responsible for a total deductible amount of $500. The plan confirmed prior to receiving these services $118.18 was applied to the enrollee's deductible. This left a remaining deductible of $381.82. CPT Code 66984 was billed to the plan in the amount of $2,000.00 and the allowed amount is $472.42. Since the enrollee had not reached their deductible, the remaining deductible of $381.82 was applied correctly as member liability. The $381.82 deductible was applied correctly, and the plan issued a payment for the remaining allowed amount of $90.60 ($472.42 - $381.82). 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 deductible for removal of cataract with insertion of prosthetic lens (CPT code 66984) provided to the enrollee on July 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health services (G0299, G0165).

You asked the Plan to pre-approve the home health services. You say that the additional skilled nursing and
aide services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not
been met.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy.

A doctor must certify the need for home health care services.

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 home health services. Our reviewer says that the additional home health services are not medically necessary. Our physician reviewer found the enrollee does not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition or to prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.

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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health services (G0299, G0165).
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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided 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 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for revision of left shoulder arthroplasty and was treated for a post-operative fever. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 

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.