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

We decided that the Plan does not have to waive the deductible for the arthrocentesis provided on August 20, 2020.
You asked the Plan to waive the deductible for the arthrocentesis. You say that you do not feel you should not have to pay the facility fee because you already paid the $35 specialist copayment. 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. Your contract with the Plan says that there is a $750 deductible that applies towards outpatient surgery services. The arthrocentesis you asked the Plan to waive the deductible for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards outpatient hospital services. This cost sharing is a contractual obligation that had not been met at the time the arthrocentesis was received on August 20, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the arthrocentesis provided on August 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from January 13, 2020, to
February 10, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that you are appealing with supporting
documentation. The Plan denied your request. The Plan says the denial of payment for these services is correct,
because this provider is out-of-network with the Plan and authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide 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 from January 13,
2020, to February 10, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea complete mandibular denture.You asked the Planto pre-approvethe denture. You say that this is medically necessary.The Plandenied your request. The Plansaysthe benefit limit has been exhausted.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 dentures once every five years.The records show that dentures were last received on October 11, 2019. Based on this information, we decided that the Plan's rules for coverage of the denture have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea complete mandibular denture.
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 stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.
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 the complexity of the patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was
admitted for acute kidney failure and COVID-19 infection. Medical conditions are stable. There are no medical
needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. While the medical record documents a need for physical and
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a
reasonable expectation that this patient 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 IRF admission and services.
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 LTACH is the appropriate level of care
for the enrollee. The Plan denied your request. The Plan says the denial of authorization for LTACH service is
correct.
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 as LTACHs and acute care hospitals are licensed to provide the same level of care,
there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute
care hospital until such time as no acute services are required, then be transferred/discharged to a lower level of
care for any ongoing long-term care needs.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 22, 2019, by an out-of-network (OON) provider.You asked the Plan to pay forthe OON services. You say that the physician depends on the hospital staff to verify eligibility, and to obtain proper authorization.The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The 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. The Plan did not pre-approve the servicesat 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 forthe medical services provided on October 22, 2019, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the prosthetic device provided.

You asked the Plan to waive the cost shares for the prosthesis. You say that you have been trying to get your copay back.The Plan denied your request. The Plan says the total cost share amount 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 prosthetic devices and related supplies. 

You have been asked to pay a 20% coinsurance for the prosthesis. The device falls within the prosthetic devices and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the cost shares for the prosthetic device provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 16, 2019, by an outof-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 has network providers
available who can provide 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 August 16, 2019,
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Part B injectable drug provided on September 23, 2020.You asked the Plan to waive the coinsurance forthe Part B injectable drug. You say that you were charged a copayment at your back specialist's office. 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 15% of the total cost for Medicare-covered Part B prescription drugs, including chemotherapy drugs. You have been asked to pay $2.22 which is 15% of the allowed amount for the Part B injectable drug. The allowed amount is $14.82. ($14.82 x 15% = $2.22). The Part B injectable drug 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 forthe Part B injectable drug provided on September 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on from July 12, 2020 to
July 13, 2020.
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 are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does
not have to pay for the home infusion therapy rendered on from July 12, 2020 to July 13, 2020.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray (D0220) provided on September 16, 2020.You asked the Plan to pay forthe first intraoral periapical x-ray. You say that you were experiencing some pain on tooth #12, and there was damage fromthe gum. You also say that the dentist took an x-ray of the tooth.The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.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 forthe first intraoral periapical x-ray (D0220) provided on September 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI scan of the knee.
You asked the Plan to pre-approve an MRI scan. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.
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 MRI scan. Our reviewer says that
the documentation does not support that the requested MRI is medically reasonable or necessary. Our physician
reviewer found there is no documentation detailing the length of pain or the existence of the diagnosis. There is
insufficient information to justify the requested study. Therefore, you do not meet criteria for the requested MRI.
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 MRI scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve an MRI scan of the knee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental exam andcleaning rendered on August 25, 2020.You asked the Plan to pay forthese services. You say that you were not made aware that the provider was out-of-network.The Plan denied your request. The Plan says the claim was processed correctly.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 supplemental dental benefits from an out-of-network provider subject to any in-network benefit maximums, limitations, and/or exclusions.We looked at the file and the Plan's rules. The file shows that you received a dental exam and cleaning from an out-of-network provider on August 25, 2020. The provider billed$54 for the exam and $95 for the cleaning. The allowed amount for these services was $19 for the exam and $41 for the cleaning, leaving a balance of $89 as your financial responsibility. The Plan cannot be held liable for payment beyond the allowed amountfor these services. Therefore, we decided that the Plan does not have to pay forthe dental exam and cleaning rendered on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the home infusion therapy services
provided from October 3, 2020, to October 9, 2020.
You asked the Plan to waive the cost shares for the services provided. You say that the prescription should be
going through Part D. 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 20% of
the plan-allowed amount for Medicare Part B prescription drugs.
You have been asked to pay 20% of the plan-allowed amount for the services provided. The services fall within
the Medicare Part B prescription drugs benefit category. Covered services include drugs you take using durable
medical equipment that were authorized by the plan. 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 cost shares for
the home infusion therapy services provided from October 3, 2020, to October 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvewheelchair accessory, manual swing-away, retractable or removable mounting hardware for joystick, other control interface or positioning accessory (CPT Code E1028).You asked the Plan to pre-approvethe accessory. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the accessory have not been met. Medicare Guidance says code E1028 is not to be used for hardware on a wheelchair tray (E0950). Therefore, we have denied E1028 because of miscoding. This should not affect the member's wheelchair.Therefore, we decided that the Plan does not have to pre-approvewheelchair accessory, manual swing-away, retractable or removable mounting hardware for joystick, other control interface or positioning accessory (CPT Code E1028).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysat the present time, medical care is ongoing, and the amount of therapy is appropriate to meet the enrollee's needs.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 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 was admitted for total hip replacement after a hip fracture resulting from a fall at her nursing home. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe collection and application of autologous blood concentrate product (D7921), two bone replacement grafts for ridge preservation (D7953 x2), first fifteen minutes of deep sedation/general anesthesia (D9222), and each subsequent fifteen-minute increment of deep sedation/general anesthesia (D9223) provided on August 14, 2020.You asked the Plan to pay forthe collection and application of autologous blood concentrate product, bone replacement grafts, and deep sedation/general anesthesia services. You say that these services were necessary due to bone loss. You also say that you were advised by a Plan representative that oral services were covered at 50%.The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.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. The record shows that you contacted the Plan on March 6, 2020, were told that oral surgery services would be covered at 50% of the maximum allowable charge, and advised you that implants would not be covered. The Plan verified that at no point during the call did youask about the coverage for the services in question.Therefore, we decided that the Plan does not have to pay forthe collection and application of autologous blood concentrate product (D7921), two bone replacement grafts for ridge preservation (D7953 x2), first fifteenminutes of deep sedation/general anesthesia (D9222), and each subsequent fifteen-minute increment of deep sedation/general anesthesia (D9223) provided on August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by a non-participating 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 a non-participating 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 has network providers available who can provide 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 by a non-participating provider