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

We decided that the Plan does not have to pay forthe medical services provided on November 28, 2019 by an out of network (OON) provider.You asked the Plan to pay for the office visit (99214). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says utilization of network providers is required when possible and available. Authorization is required 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 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 haveto pay for the medical services provided on November 28, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvegroup three power wheelchair accessories (a seat elevator and a mud guard) for the enrollee.You asked the Plan to pre-approve the accessories. You say that the enrollee has complete paraplegia, which is a nerve conditions, and clearly qualifies him for this wheelchair.The Plan denied your request. The Plan says these are not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The seat elevator does not primarily serve a medical purpose. The mud guard is intended for use outside of the home, and also does not serve a medical purpose.Therefore, we decided that the Plan does not have to pre-approve group three power wheelchair accessories (a seat elevator and a mud guard) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive periodontal evaluation (D0180), the biopsy of oral tissue (D7286), the initial 15 minutes of general anesthesia (D9222), and the additional 15 minutes of general anesthesia (D9223) provided from October 1, 2019 to October 25, 2019.You asked the Plan to pay forthe dental services. You say that you had 2 biopsies. You say that on October 25, 2019 you had the second biopsy, this time with anesthesia, but the provider only charged you for the anesthesia. You say that you were charged $448 for the anesthesia that you received on October 25, 2019. You say that you were charged $442 forthe biopsy and other services that you received on October 1, 2019. You say that you paid for all of this because the provider does not take your plan. You also say that you received a bill for $896 for anesthesia that you received on October 2, 2019, butthat you only paid $442.The Plan denied your request. The Plan says the dental services that you received are not covered under your medical plan.Medicare generally does not cover dental services. The Plan follows the same rule.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. The record shows that the anesthesia bill you received for October 2, 2019 was paid in full by the Plan, with no liability for you. The record shows that the $448 that you paid for anesthesia was applied to the general anesthesia that you received on October 25, 2019. The record also shows that the $442 that you paid was correctly applied to the biopsy that you received on October 1, 2019.Therefore, we decided that the Plan does not have to pay forthe comprehensive periodontal evaluation (D0180), the biopsy of oral tissue (D7286), the initial 15 minutes of general anesthesia (D9222), and the additional 15 minutes of general anesthesia (D9223) provided from October 1, 2019 to October 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe resin-based composite provided on December 12, 2019.You asked the Plan to pay forthe resin-based composite. You say that your insurance record showed that you had over $600 remaining on your dental benefits. You also say that your remaining benefits should have been paid.The Plan denied your request. The Plan says your annual maximum benefit had 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.Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on December 12, 2019 and your annual maximum benefit had been exhausted.Therefore, we decided that the Plan does not have to pay forthe resin-based composite provided on December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 25, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that you are appealing with records. 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 the ordering physician is also out-of-network 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 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 October 25, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 15 additional fractions of RCSCLC image guided radiology therapy.
You asked the Plan to pre-approve 15 additional fractions of RCSCLC image guided radiology therapy. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 15 additional fractions of RCSCLC image guided radiology therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee, with poor response to chemotherapy and symptomatic disease is being offered palliative radiation. Concurrent chemotherapy with 6 weeks of radiation for palliation is not standard therapy, particularly for patients with extensive stage small cell lung cancer (SCLC). The case file does not provide a rationale for this treatment in this clinical setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 15 additional fractions of RCSCLC image guided radiology therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 15 additional fractions of RCSCLC image guided radiology therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on November 13, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal wasrequested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on November 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and bitewings provided by an OON provider on November 11, 2019.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and bitewings. You say that you have had this same dentist for 15 years. You also say that you understood that these services would be covered in-network or out-of-network. The Plan denied your request. The Plan says these services were rendered by an out-of-network dentist. The Plan also says that this plan only has dental coverage with in-network providers.
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 when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and bitewings provided by an OON provider on November 11, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on October 31, 2019.You asked the Plan to pay forthe laboratory services. You say that the services should be covered.The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. OriginalMedicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on October 19, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the special eye evaluation provided from January 25, 2019 through October 25, 2019. You asked the Plan to waive the copayment for the special eye evaluation. You say that a copayment should not apply for this service as it was a follow-up visit for cataract surgery you had on October 17, 2019. You state this was not a routine annual eye exam. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).  The Plan spoke with the office who indicated you did have follow-up visit on October 25, 2019 but it was not billed, the provider's office indicated that an eye evaluation was performed as well, the services were a gonioscopy which is a diagnostic test for glaucoma. The Medicare-allowed amount for the eye exam is less than the set $50 copayment; therefore, you have been asked to pay the lesser amount of $30.84 for the eye exam. 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 special eye evaluation provided from January 25, 2019 through October 25, 2019
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repetitive transcranial magnetic stimulation treatments.
You asked the Plan to pre-approve the treatments. You say that this is medically necessary for bipolar disorder. The Plan denied your request. The Plan says this is not covered for treatment of bipolar disorder.
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 treatments. Our reviewer says that the requested treatments are not considered medically reasonable and necessary in this case. Our physician reviewer found these treatments are not medically necessary for patients with bipolar disorder. In this setting, the requested service would not meet the requirements.
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 treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve repetitive transcranial magnetic stimulation treatments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the office visit (99214 and 99204). You say that you would like
reconsideration because there are only two dentists who are qualified to render the necessary services. The Plan
denied your request. The Plan says there are network providers available who can provide this service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the medical services to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a colonoscopy provided on December 31, 2019.
You asked the Plan to waive the deductible for a colonoscopy. You say that this was a screening and you disagree with the charges. 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. Your contract with the Plan says that there is a $1,250 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you received a diagnostic colonoscopy on December 31, 2019. The record shows that you had paid $0 toward the $1,250 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount is $989.28. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,250 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time a colonoscopy was received on December 31, 2019. Therefore, we decided that the Plan does not have to waive the deductible for a colonoscopy provided on December 31, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Perphenazine tablets.
You asked the Plan to pre-approve Perphenazine tablets. You say that the enrollee needs this medication for her dementia. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Perphenazine tablets.
Benefits for Perphenazine tablets 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: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve Azathiroprine 50mg tablet for the enrollee.You asked the Planto pre-approvethe tablet. You say that switching to another medication such as CellCept may worsen the enrollee's symptoms.The Plandenied your request. The Plansaysthe plan only has Part B coverage.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approveAzathiroprine 50mg tablet for the enrollee
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 21, 2019 by a non-plan provider.You asked the Plan topay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-plan 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 forthe medical services provided on November 21, 2019 by a non-plan provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 10, 2020 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you were told the provider would be covered.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 forthe medical services provided on January 10, 2020 by an out of network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 16, 2019 to enrollee by an out of 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 referring provider 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 forthe medical services provided on December 16, 2019 to enrollee by an out of network (OON) provider.
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 the enrollee needs LTACH care. The
Plan denied your request. The Plan says the enrollee has been weaned from the ventilator and can be managed
outside of the acute hospital setting.
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 the patient is currently undergoing treatment at an ACH for respiratory failure and
renal failure. The enrollee was transiently intubated/ventilated but is no longer intubated/ventilated. The
enrollee continues to receive hemodialysis. There is no evidence that the enrollee requires services that are not
currently available. As LTACHs and ACHs 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 ACH until such
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for
any ongoing LTC 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.