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

We decided that the Plan has to pay for the services (G2012) provided on February 11, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is not a
covered benefit.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
You were provided the services by a contract provider. The file does not show that the Plan provided notice
that the services would not be covered. Under Medicare rules, this means the services is considered approved
by the Plan. Therefore, we decided that the Plan has to pay for the services (G2012) provided on February 11,
2021.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on October 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is insufficient information to corroborate the services.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation submitted by the non-contract provider does not contain medical records for the date of service in question. Without records, it cannot be determined that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the services provided on October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 3 surgical extractions (D7210) and a periapical x-ray (D0220) provided on August 26, 2020.

You asked the Plan to pay for the dental services. You say that you were not aware that the dentist had opted out of Medicare until you got to your appointment. You say that at this time it was too late to find another dentist. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot be made for dental services that you receive from a dentist that has opted out of Medicare.

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, dental services performed by a dentist that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 3 surgical extractions (D7210) and a periapical x-ray (D0220) provided on August 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on November 20, 2020.

You asked the Plan to pay for laboratory services. You say that the patient is in a nursing facility and does not have an option on what lab service to use. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on November 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from October 22, 2019, through October 31, 2019.

You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says that in order to determine if the member's foreign services are medically necessary, the payment request must include an itemized bill which lists the services that were rendered.

The Plan contract says that an itemized bill must be submitted to the Plan. 

We looked at the file and the Plan's rules. The file does not contain an itemized bill that lists the services that were provided. Therefore, we decided that the Plan does not have to pay for an inpatient admission provided from October 22, 2019, through October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx testing rendered on October 20, 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 were not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that next generation sequencing 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of intrahepatic bile duct adenocarcinoma. The documentation does not support that the FoundationOne CDx testing would impact the management and the outcome of the enrollee in this case. The testing was not medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx testing rendered on October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 8, 2021.
You asked the Plan to waive the copayment for the office visit. You say that the injections didn't work and you have to wait to get any other injection. You say that you don't want to pay for the visit. 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 $20 copayment for a specialist visit.
You have been asked to pay a $20 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 services were provided by a specialist during the visit. 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 office visit provided on February 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the CPAP supplies provided on January 19, 2021.

You asked the Plan to waive the cost share for the CPAP supplies. You say that you do not believe you should have to pay because you have never paid this much for your supplies before. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $125 deductible that applies towards in-network oxygen equipment and 10% of the total cost for in-network oxygen and oxygen related equipment.

The in-network oxygen equipment you asked the Plan to waive the cost share for falls within the "Durable medical equipment (DME) and related supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $125 deductible that applies towards in-network oxygen supplies and 10% of the total cost for in-network oxygen and oxygen related equipment.

This cost sharing is a contractual obligation that had not been met at the time the CPAP supplies was received on January 19, 2021. Therefore, we decided that the Plan does not have to waive the cost share for the CPAP supplies provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on December 23, 2020.

You asked the Plan to pay for the office visit. You say that the services were medically necessary to properly assess and treat the patient. You say that payment for the claim should be reconsidered. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on December 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on August 18, 2020, to August 19, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you think this was billed in error. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $395 copayment per day for days 1-4. There is a $0 copayment for additional days for inpatient hospital care/in-network. You have been asked to pay a $395 copayment per day for days 1-4 for an inpatient hospital stay. The total amount you are being asked to pay is $395. An inpatient hospital stay falls within the inpatient hospital care/in-network 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 an inpatient hospital stay provided by a participating provider on August 18, 2020, to August 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that you are non-weight bearing on the left extremity, and weight bearing as tolerated on the right. The Plan denied your request. The Plan says the records do not indicate a need for an intensive 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 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a fibula fracture after a fall. 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.
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested device. You say that you have tried every method to control your sugar. The Plan denied your request. The Plan says the requested item is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary only under certain medical indications. We looked at the file and Medicare rules. The file shows that a Medtronic device is considered a non-therapeutic continuous glucose monitor. Medicare only covers therapeutic continuous glucose monitors. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an Euflexxa injection provided on December 4, 2020.

You asked the Plan to waive the coinsurance for the Euflexxa injection. You say that you were not told about the additional cost for the injection. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for chemotherapy drugs, infusion drugs, and all other drugs covered under Medicare Part B.

You have been asked to pay $104.43 which is 20% of the allowed amount for the Euflexxa injection. The allowed amount is $522.15. ($522.15 x 20% = $104.43). The Euflexxa injection falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Euflexxa injection provided on December 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Optimizer implantable pulse generator.
You asked the Plan to pre-approve the generator. You say that this is medically necessary. The Plan denied your request. The Plan says there have not been enough studies to show that this procedure is safe or helpful.
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 generator. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found cardiac contractility modulation therapy is a relatively newer technology which, although FDA approved, has limited randomized data showing modest benefit with regard to quality of life and walk time scores in patients already on maximal medical therapy. A referral for Optimizer cardiac contractility modulation therapy would not be considered medically necessary or reasonable at this time in this clinical situation, based on the published data. 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 generator have not been met. Therefore, we decided that the Plan does not have to pre-approve the Optimizer implantable pulse generator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and complete full mouth series of intraoral x-rays (D0210) provided on December 9, 2020.

You asked the Plan to pay for the comprehensive evaluation and x-rays. You say that these services should be paid per the Plan's brochure. The Plan denied your request. The Plan says one comprehensive or periodontal evaluation can be covered every 3 years, and one full mouth or panoramic x-ray can be covered every five years. The Plan paid for you to have a comprehensive evaluation and a full mouth x-ray series on October 7, 2019. This exceeds the frequency allowed by this benefit; therefore, these services cannot be covered.

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 were provided in a frequency greater than what is covered under this benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and complete full mouth series of intraoral x-rays (D0210) provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for somatosensory testing (95927 and 95938) provided on August 4, 2020.
You asked the Plan to pay for the somatosensory testing. You say that you would like reconsideration because this claim was billed with the appropriate place of service code. The Plan denied your request. The Plan says the member was registered inpatient on the billed date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT codes 95927 and 95938 are not supported in the record. Specifically, the record indicates that the member was registered inpatient on the billed date of service. There is a more appropriate place of service code for the services billed. Additionally, these are technical component only codes meaning that the facility would be responsible for payment to any vendor. Based on this information, we decided that Medicare rules for coverage of the somatosensory testing have not been met. Therefore, we decided that the Plan does not have to pay for somatosensory testing (95927 and 95938) provided on August 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing
facility, home with home health services or home with outpatient therapy.
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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
weakness and a fall. Medical problems are stable. 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.
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on August 12, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at 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 for the services provided to the enrollee by an out-of-network provider on August 12, 2020.