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

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on
September 18, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you should not owe
anything for the injection. The Plan denied your request. The Plan says the claims were processed correctly,
and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare Part B prescription drugs.
You received a Medicare Part B drug on September 18, 2020. The allowed amount is $377.01 and 20% of that
is $75.40.
You have been asked to pay the total coinsurance amount of $75.40 for a Medicare Part B drug. A Medicare
Part B 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 for a Medicare Part B drug provided on September 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2740) and core build up (D2950) for tooth # 30.
You asked the Plan to pre-approve the dental services. You say that these services were approved by the Plan over 1 year ago. The Plan denied your request. The Plan says crowns and core build up are covered once per tooth every 5 plan years. The Plan says that the frequency limits have been reached.
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 the services are listed as covered, the frequency limits have been reached. The record shows that the Plan paid for a crown and core build up for tooth # 30 that you received on February 18, 2019. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D2740) and core build up (D2950) for tooth # 30.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the orbits and ears.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the results of the ultrasound of the head and neck were not provided.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the records provided do not show a valid indication for a CT scan of the orbits or IACs without contrast at this point. There is no physical exam of the external canals in the records. Also, there is no documentation of hearing loss or even testing. Furthermore, a CT without contrast is likely to be not beneficial under any circumstances if there is a suspicion of tumor or even infection. Likewise, you complain of neck pain/swelling, and the neck would not be in the field of view in this scan. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the orbits and ears.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says testing is only happening once per day.

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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you do not meet the criteria above for insulin use and monitoring frequency. You are not using insulin three times per day. 

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from
January 16, 2020, to January 21, 2020.

You asked the Plan to waive the copayment for inpatient hospital care. You say that the nurse told you that you
would only owe a copayment for four days. The Plan denied your request. The Plan says the claims were
processed correctly, and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250
copayment for days 1-7 for inpatient hospital care.

You had an inpatient hospital stay from January 16, 2020, to January 21, 2020. Therefore, you are responsible
to pay a $250 copayment for days 1-5 (January 16, 2020, to January 20, 2020). $250 (copayment) x 5 (inpatient
days) = $1,250.

You have been asked to pay the total copayment amount of $1,250 for inpatient hospital care. Inpatient hospital
care falls within the inpatient hospital care benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment
for inpatient hospital care provided from January 16, 2020, to January 21, 2020.
Appeal type: SNF
Decision: Unfavorable

Explanation of decision
We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says skilled services are no longer required, and continuation of SNF is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no documented skilled nursing or skilled therapy needs. You appear to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of condition. Your care needs at this point are custodial, and as a practical matter, can be provided at a lower level of 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee.
You asked the Plan to pre-approve this device. You say that this device is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a pneumatic compression device (E0652). The Maximus Physician Reviewer determined that the requested Pneumatic Compression Device is medically necessary. The Plan argues that there is no objective evidence that the enrollee has truncal, abdominal, or chest edema, which is a requirement for Medicare coverage of this item.
Based on the medical records provide, our Medical Director has concluded that the Plan is correct in this case. The documentation does not support that the enrollee had failed 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. Medicare coverage criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 48 trips for routine transportation
(A0120).
You asked the Plan to pre-approve the additional trips. You say that you are requesting a reconsideration of the
Plan's denial. The Plan denied your request. The Plan says your request exceeds the allowable transportation
benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case.
We looked at your request, the records in the case file, and the Plan's rules. Based on this information, we
decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the Plan
benefit provides an allowance for 24 one-way trips per calendar year, in which you have utilized 23 trips thus
far. Your request for an additional 48 trips exceeds the Plan's benefit allowance for the calendar year.
Therefore, we decided that the Plan does not have to pre-approve an additional 48 trips for routine
transportation (A0120).
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 requested out-of-network provider.

You asked the Plan to pre-approve the physician's services. You say that you have had several surgeries on your eyes and now you are going completely blind. You say that you were referred to this physician because he is the best and you would like to see if he can help you. The Plan denied your request. The Plan says the provider you requested is not part of your primary care physician's network. You must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered.

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 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 requested out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient hospital care.

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 that the inpatient level of care is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the inpatient admission for your planned surgery is not medically necessary; however, no medical records were included with the case file. Without medical records, a determination based on medical necessity cannot be supported. Therefore, we decided that the Plan has to pre-approve acute inpatient hospital care.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Prolia injection provided on December
2, 2020.

You asked the Plan to waive the coinsurance for a Prolia injection. You say that you were told that your
insurance would fully cover the injection. The Plan denied your request. The Plan says the claims were
processed correctly, and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare Part B prescription drugs.

You received a Prolia injection on December 2, 2020. The total allowed amount is $1,207.20 and 20% of that is
$241.44.

You have been asked to pay the total coinsurance amount of $241.44 for a Prolia injection. A Prolia 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 a Prolia injection provided on December 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental surgery procedure (41899) and the x-ray exam of
the teeth (70300) provided September 25, 2020.

You asked the Plan to pay for the dental services. You say that the services provided were medically necessary.
The Plan denied your request. The Plan says the requested services are dental in nature and therefore not
covered by Original Medicare. In addition, the requested services are not covered under the enrollee's
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. In addition, the requested services are not covered under Original
Medicare because they are dental in nature. Therefore, we decided that the Plan does not have to pay for the
dental surgery procedure (41899) and the x-ray exam of the teeth (70300) provided September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment - includes placement
(D6057) and the abutment supported porcelain/ceramic crown (D6058).

You asked the Plan to pay for the dental services (D6057, D6058). You say that the requested services were
necessary. The Plan denied your request. The Plan says the requested services are not covered by 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. The Plan lists specific codes eligible for coverage on pages 4-73
through 4-87 of the EOC. The requested services (D6057, D6058) are not listed in the dental benefit; therefore,
they are excluded from coverage. Therefore, we decided that the Plan does not have to pay for the custom
fabricated abutment - includes placement (D6057) and the abutment supported porcelain/ceramic crown
(D6058).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the rituximab injections and chemotherapy administration provided on November 11, 2020.

You asked the Plan to waive the coinsurance for the rituximab injections and chemotherapy administration. You say that you were advised you had an authorization and were given the Part D copayment. You say that you want the claim reviewed against the authorization.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 15% coinsurance for each Medicare-covered chemotherapy drug to treat cancer and the administration of that drug.

You have been asked to pay a total of $894.27 for the rituximab injections and chemotherapy administration.

The rituximab injections and chemotherapy administration fall within the "Medicare Part B Prescription Drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance for the rituximab injections and chemotherapy administration provided on November 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on July 1, 2020.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950), the pontic (D6245), the retainer crown (D6740), the surgical extraction (D7210), and the bone replacement graft (D7953) provided on May 12, 2020.

You asked the Plan to pay for the dental services. You say that the services should be reimbursed under medical and not dental. You also say that the services were provided as a result of an accident. The Plan denied your request. The Plan says the services you received are dental in nature. The Plan says that you will be reimburse up to $200 for dental services each calendar year. The Plan says that the $200 benefit has been exhausted. The Plan also says that dental services are not reimbursable and are a non-covered benefit if they are not related to jaw reconstruction or for extractions done in preparation for radiation treatment for neoplastic disease involving the jaw.

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, there is a maximum reimbursement amount of $200 for dental services. The record shows that the Plan paid $200 for the root canal that you received on the date of service in this case. Additionally, the services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the core build up (D2950), the pontic (D6245), the retainer crown (D6740), the surgical extraction (D7210), and the bone replacement graft (D7953) provided on May 12, 2020.