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

We decided that the Plan does not have to pay for Covid testing provided on August 7, 2020.
You asked the Plan to pay for Covid Testing. You say that you went to dinner with two friends and they later
tested positive for Covid. You stated it wasn't until August 25th that the state officer in Montgomery was on
the news advising per CDC not to get tested unless you show signs and symptoms.
The Plan denied your request. The Plan says the claim was denied and was processed correctly per the plan
benefits for services rendered by a non-participating laboratory with Medicare. Outreach was also made to the
Centers for Medicare & Medicaid Services (CMS) regarding benefits for non-participating Medicare providers.
From the outreach made to the CMS portal on September 22, 2020, a Medicare Advantage (MA) organization
must ensure that Medicare-covered basic benefits are provided only by providers that have signed participation
agreements ("provider agreements") with CMS, and by suppliers approved by CMS as meeting conditions for
coverage of their services including Clinical laboratories (a CMS-issued CLIA certificate or a hospital-based
exemption from CLIA). In addition, the case was reviewed with the Legal Department of the Health Plan. Based on their research, providers must be enrolled in Medicare. The rules are allowing for
flexibility and giving providers the opportunity to easily enroll in Medicare or treat but it seems that CMS still
wants the providers to participate in Medicare to treat Medicare beneficiaries.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who is not a Medicare eligible provider.
The services at issue in this appeal were not provided by an eligible Medicare provider. You did not follow
your Plan contract rules when obtaining these services. Therefore, we decided that the Plan does not have to
pay for Covid testing provided on August 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair and the other requested items/accessories.
You asked the Plan to pre-approve the DME. You say that the enrollee is unable to walk without the wheelchair. The Plan denied your request. The Plan says the enrollee had an in-home assessment by a physical therapist (DME). The Plan says the therapist states that the enrollee's current power wheelchair (group 2) is less than a year old, and it only needs minor repair. The Plan says the therapist states that the enrollee needs to have an exam (cognitive assessment) by their doctor to make sure that they can use the power wheelchair safely before the repair. The Plan states this is consistent with Medicare guidelines and the enrollee has been approved for the repair of their power wheelchair. The Plan states they are not able to approve the request for a new power wheelchair.
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 DME have not been met. The enrollee's current power wheelchair (group 2) is less than a year old, and it only needs minor repair. The reasonable useful lifetime of durable medical equipment is determined through program instructions. In the absence of program instructions, A/B MACS (B) may determine the reasonable useful lifetime (RUL) of equipment, but in no case can it be less than 5 years. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair and the other requested items/accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day Sensor Kit.
You asked the Plan to pre-approve the Freestyle Libre 14-day Sensor Kit. You say that the enrollee is currently using a home blood glucose monitor, test their blood sugar 3-4 times daily, and is injecting insulin daily. You say that the enrollee's insulin regimen changes frequently due to fluctuating blood sugars. You say that the enrollee has follow-ups every 6 months for their diabetes. The Plan denied your request.
The Plan says the enrollee is on a long acting insulin preparation with no adjustment. The Plan says that the enrollee's doctor did not submit any information about blood sugar testing in the records and how that information is being used.
The Plan follows Medicare rules. Medicare rules say that when any of the coverage criteria for a therapeutic CGM are not met, the related supplies will be denied as not reasonable and 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 Freestyle Libre 14-day Sensor Kit. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee receives insulin shots once daily. We were not given a blood glucose log documenting how often the enrollee is checking. Our physician reviewer found that the CGM supplies are not considered reasonable and necessary based on the documentation provided. 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 Freestyle Libre 14-day Sensor Kit have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14-day Sensor Kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the rebase complete maxillary denture (D5710) and unspecified preventative procedure (D1999) provided on July 27, 2020.
You asked the Plan to pay for the rebase complete maxillary denture and unspecified preventative procedure. You say that the services you received were necessary for your condition. The Plan denied your request. The Plan says your EOC does not provide a benefit for the services requested.
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 rebase complete maxillary denture (D5710) and unspecified preventative procedure (D1999) provided on July 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EKG and cardiac device evaluation provided on August 13, 2020.
You asked the Plan to waive the copayment for the EKG and cardiac device evaluation. You say that you saw a provider for the office visit and a provider for two tests. You say that the second copayment for the tests were applied in error. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for diagnostic procedures and tests at an in-network specialist's office. You have been asked to pay a $45 copayment for the EKG and cardiac device evaluation. The EKG and cardiac device evaluation falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 EKG and cardiac device evaluation provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the hip x-ray, triamcinolone acetonide injection and office visit provided on August 10, 2020.
You asked the Plan to waive the cost share for the hip x-ray, triamcinolone acetonide injection and office visit. You say that you have never been charged for all of this with your regular doctor. You say that you are disputing the charges. The Plan denied your request. The Plan says the cost share applied correctly.
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 your deductible is $250. This is the amount you have to pay out-of-pocket for in-network and/or out-of-network services before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Your contract also says that you must pay $35 for each Medicare-covered visit with an in-network specialist.
The item or service you asked the Plan to waive the cost share for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" and "Medicare Part B prescription drugs" benefit categories. The Plan has followed Medicare rules by clearly disclosing in the contract that your $250 deductible applies to Part B drugs and outpatient diagnostic tests. This cost sharing is a contractual obligation that had not been met at the time the hip x-ray and triamcinolone acetonide injection were received on August 10, 2020. Therefore, $57.89 has been applied to your deductible.
You have also been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the services were provided by a specialist. 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 share for the hip x-ray, triamcinolone acetonide injection and office visit provided on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician's services provided on August 25, 2020.
You asked the Plan to waive the copayment for the physician's services. The Plan denied your request. The Plan says the vision exam you had on August 25, 2020 was diagnostic for other conditions and was in addition to the diabetic eye exam.
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 $40 copayment for Vision Care, Medicare-covered exams. You have been asked to pay $40 copayment for the physician's services. The physician's services falls within the Vision Care, Medicare-covered exam 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 physician's services provided on August 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystourethroscopy provided on June 2, 2020.
You asked the Plan to waive the copayment for the cystourethroscopy. You say that all copayments were waived for 2020. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for provider and professional services at an in-network specialist's office. You have been asked to pay a $50 copayment for the cystourethroscopy. The cystourethroscopy falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plans says that only out-of-pocket costs for in-network primary care, behavioral health and telehealth visits through the end of 2020 are being waived. The cystourethroscopy is considered a surgical service that was provided by a specialist.
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 cystourethroscopy provided on June 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture provided on September 9, 2020.
You asked the Plan to pay for the maxillary partial denture. You say that your provider told you this service would be covered. The Plan denied your request. The Plan says this service is not a covered 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 maxillary partial denture provided on September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 3, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says in most cases the care you receive from an out-of-network provider will not be covered. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain authorization from the plan prior to seeking care.
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 physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on June 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the retainer crowns (D6750 x 2) and pontic (D6245) provided on March 13, 2020.
You asked the Plan to pay the full amount for the dental services. You say that you were advised the services were approved. You say that you are on disability. You say that had you known the services would not be full covered, you would not have gotten them. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,500. The Plan says that the maximum benefit was exhausted in the processing of this claim. The Plan says after the annual maximum is exhausted, any remaining charges are your responsibility.
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 maximum benefit of $1,500 was exhausted. The record shows that the Plan paid $126 for dental services that you received on February 5, 2020. The record shows that the Plan paid $1,374 towards the dental services that you received on the date of service in this case, thus exhausting the annual maximum benefit. Therefore, we decided that the Plan does not have to pay the full amount for the retainer crowns (D6750 x 2) and pontic (D6245) provided on March 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator to use in the home.
You asked the Plan to pre-approve the oxygen concentrator. You say that the requested use of oxygen is medically necessary for management of the enrollee's migraines. You say that oxygen will help the enrollee manage her pain and regain control over her life. The Plan denied your request. The Plan says a home oxygen concentrator is not medically necessary.
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 oxygen concentrator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found oxygen for Migraines is not supported by evidence-based studies. Our physician reviewer found that there is no documentation of hypoxemia. 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 oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator to use in the home.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 15, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on July 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a bilateral diagnostic digital breast tomosynthesis billed with CPT code 77062.
You asked the Plan to pay for the bilateral diagnostic digital breast tomosynthesis billed with CPT code 77062. The Plan denied your request. The Plan says the CPT code in dispute has a status code of "I" which is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate HCPCS/CPT code. The rules say that HCPCS/CPT codes with a status indicator of "I" are not recognized by Medicare and will not be paid. Medicare uses another code for reporting of, and payment for, these services. We looked at the file and Medicare rules. We find that payment for CPT code 77062 is not supported. Specifically, CPT code 77062 has a status indicator of "I" and will not be paid for by Medicare. This service should be reported with a code that is recognized by Medicare. Therefore, we decided that the Plan does not have to pay for a bilateral diagnostic digital breast tomosynthesis billed with CPT code 77062.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient hospital services.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee has been risk stratified by the KORT criteria. You say that, per this risk stratification, she is expected to require medically necessary inpatient hospital care based on complex medical factors such as patient history, comorbidities, current medical needs, severity signs and symptoms, and risks of an adverse event. The Plan denied your request. The Plan says that the notes provided do not show why the enrollee needs to be admitted as inpatient. The Plan says that the enrollee can get care at the hospital while in observation.
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 acute inpatient hospital care is medically reasonable and necessary in this case. Our physician reviewer found the enrollee is indicated for right total knee arthroplasty. She has significant comorbidities, including obesity (a body mass index greater than 45), chronic obstructive pulmonary disease, fatty liver disease, hyperlipidemia, chronic kidney disease, and hypertension. Additionally, there are significant functional mobility barriers in her home that will require climbing 15 steps. The attending physician expects that the enrollee requires inpatient admission (greater than 2 midnights) for management of her comorbidities and to overcome mobility barriers. These issues are well-documented in the medical records. Our physician reviewer found that the request for an inpatient hospital stay is warranted as medically reasonable and necessary. 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 has to pre-approve inpatient hospital services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an L1-S2 Posterior Spinal Fusion with decompression of L1-S1.
You asked the Plan to pre-approve the spinal surgery. You say that the records provided support the medical necessity of the requested service. The Plan denied your request. The Plan says the enrollee has not received a second opinion. The Plan says that there is no documentation that the enrollee completed conservative measures within the past year.
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 spinal surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation provided does not show a recent and adequate trial of conservative measures, including recent physical therapy. Our physician reviewer says that, without documentation of recent physical therapy, the medical necessity of a multilevel spine surgery has not been supported and the criteria for coverage have not been 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 the spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve an L1-S2 Posterior Spinal Fusion with decompression of L1-S1.