Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral periapical x-rays (D0220, D0230) provided on December 16, 2020.

You asked the Plan to pay for the x-rays. You say that you were directed to use this dental provider by the Plan. The Plan denied your request. The Plan says this type of x-ray is not covered by your dental 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 intraoral periapical x-rays (D0220, D0230) provided on December 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
December 2, 2020, through December 6, 2020.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the
inpatient admission was not medically necessary.
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 pay for acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found that in this case, the enrollee presented to the emergency department with severe
abdominal pain and was found to have an elevated creatinine with a proximal ureteral calculus causing
hydronephrosis and hydroureter with decreased renal cortical enhancement indicative of altered function
consistent with acute kidney injury. The admitting physician documented an admission to observation. The
medical record does not indicate a medical reason to justify the continued stay in an inpatient setting. The
elements of the coverage rule are not satisfied. The requested service cannot be recommended.
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 does not have to pay for the acute inpatient hospital care provided from December 2, 2020, through
December 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor and supplies provided January 3, 2021.

You asked the Plan to pay for the therapeutic continuous glucose monitor and supplies. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the documentation submitted did not sufficiently document the member's medical condition to support the medical necessity for the billed supply code.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. In this case, there are no chart notes indicating that the enrollee has satisfied the coverage criteria for the therapeutic continuous glucose monitor. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor and supplies provided January 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit and the ECG
provided on December 4, 2020.
You asked the Plan to waive the copayment for the specialist office visit and the ECG. You say that an ECG
was not performed, and the doctor did not listen to your heart. You say there was a discussion about how you
were doing and medications. 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 a $20
copayment per visit to a specialist and a $0 copayment for an electrocardiogram (EKG).
You have been asked to pay a $20 copayment for the specialist office visit and a $0 copayment for the ECG.
The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits"
benefit category. The ECG falls within the "Outpatient diagnostic tests and therapeutic services and supplies"
benefit category. The medical record shows you were seen for a follow-up office visit and received an ECG inoffice.
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 specialist office visit and the ECG provided on
December 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor system.
You asked the Plan to provide a therapeutic continuous glucose monitor system. You say that the enrollee needs a CGM because of hypoglycemia. The Plan denied your request. The Plan says the enrollee is not diabetic and is not using insulin.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee is not diabetic and does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of previous root canal therapy (D3346) provided on November 2, 2020.
You asked the Plan to pay for the retreatment of previous root canal therapy. You say that you cannot pay for this service. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the retreatment of previous root canal therapy (D3346) provided on November 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 6, 2020.
You asked the Plan to pay for the lab services. The Plan denied 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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab
services provided on October 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on
December 28, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered
service.
The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels,
except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or
documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease.
We looked at the file and Medicare rules. Per LCD L36358, the requested risk assessment panel is not covered.
Based on this information, we decided that Medicare rules for coverage of the testing have not been met.
Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided
on December 28, 2020.
Appeal type: ER
Decision: Unfavorable

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $50 co-payment for emergency care. You can find this information in Chapter 4 on page 65 of the Plan's 2020 Evidence of Coverage (EOC).

You asked the Plan to waive the co-payment for emergency care. You say that you got a letter stating that co-payments were waived through the end of December 2020. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 co-payment for emergency care.

You have been asked to pay a $50 co-payment for emergency care. Emergency care falls within the emergency 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 co-payment for emergency care provided on December 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency
transport (A0428-GY), ground mileage, per statute mile (A0425-GY), and basic support routine supplies
(A0382-GY) provided October 28, 2020.
You asked the Plan to pay for the non-emergency ambulance service. You say that your assisted living facility
called for the ambulance transport for an emergency, and you should not be held liable for the bill. The Plan
denied your request. The Plan says the services as billed are excluded from Medicare coverage.
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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the non-emergency ambulance transportation (A0428-GY, A0425-GY, A0382-GY) have not been
met. Specifically, the services at issue were billed with a GY modifier. The Plan cannot pay for the services as
billed by the non-contracted provider. Therefore, we decided that the Plan does not have to pay for the
ambulance service, basic life support, non-emergency transport (A0428-GY), ground mileage, per statute mile
(A0425-GY), and basic support routine supplies (A0382-GY) provided October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the root canal (D3330) provided on December 10, 2020 by an out-of-network provider.
You asked the Plan to waive the cost-share for the root canal. You say that this was an urgent service due to a quick onset of severe pain. You searched for the first dentist who could see you as soon as possible. The network status of this provider was not on your mind due to the urgency of the situation. The Plan denied your request. The Plan says the cost sharing and your responsibility for out-of-network services have been 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 50% coinsurance for root canals. The contract also says that providers are paid based on a maximum allowable charge. You may be billed more by an out-of-network provider if the charge is greater than the maximum allowable charge made by the Plan to the provider.
You have been asked to pay $1,180 for the root canal. The provider billed the Plan for $1,450. The Plan's maximum allowable charge (which is the rate in-network providers have agreed to be paid) for this root canal service is $540. You are responsible for 50% coinsurance for root canals, so you are responsible for 50% of the $540 allowable amount ($540 x 50% = $270) as well as the difference between the Plan's maximum allowable charge and the amount the provider billed ($1,450 - $540 = $910). ($270 + $910 = $1,180). 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 root canal (D3330) provided on December 10, 2020 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine ophthalmological examination provided on
January 15, 2021.
You asked the Plan to pay for the routine ophthalmological examination. You say that you did not know that you had to see an in-network provider. The Plan denied your request. The Plan says members must use a doctor in our vision network.
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by the Plan's vision provider. We looked at the file and the Plan's rules. The file shows that the provider at issue in this case is not part of the Plan's vision providers. Based on this information, we decided that the Plan's rules for coverage of the routine ophthalmological examination have not been met. Therefore, we decided that the Plan does not have to pay for a routine ophthalmological examination provided on January 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for fitness equipment on November 17, 2020.
You asked the Plan to pay for the fitness equipment. You say that the fitness equipment should be covered
under their plan benefit. The Plan denied your request. The Plan says you have already received the maximum
$150 Wellness Allowance reimbursement.
The Plan must follow Medicare rules. The plan says they will cover up to $150 Wellness Allowance for the
year. You already received the full allotment for this allowance on June 6, 2020. Coverage of the fitness
equipment exceeds this allowance.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the fitness equipment have not been met. Therefore, we decided that the Plan does not have to pay
for fitness equipment on November 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) provided November 17, 2020.
You asked the Plan to pay for the determination of refractive state. You say that you need an eye exam and vision test every 6 months due to previous diagnoses of brain tumor and aneurysm in brain. The Plan denied your request. The Plan says routine eye care is not covered under your benefits.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) provided November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider from September 17, 2019, to January 24, 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 by an out-of-network provider from September 17, 2019, to January 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
November 3, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that this service should be covered.
The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation
(D0150) and is limited to one procedure every three plan years. The record shows that you received a
comprehensive oral evaluation (D0150) on March 13, 2018, and your comprehensive oral evaluation benefit
has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral
evaluation (D0150) provided on November 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove for a therapeutic continuous glucose monitor (CGM) (K0553).
You asked the Plan to preapprove for the CGM. You say that the CGM should be approved. The Plan denied your request. The Plan says the enrollee does not meet the coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove for a therapeutic continuous glucose monitor (CGM) (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (80305, 99214) provided on August 4, 2020 by an out of network provider.
You asked the Plan to pay for the office visit. You say that you used the point-of-sale option in the past and pre-authorization was not required. The Plan denied your request. The Plan says the out-of-network services were not pre-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 service 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 an office visit (80305, 99214) provided on August 4, 2020 by an out of network provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an abdominal MRI.
You asked the Plan to pre-approve magnetic resonance (e.g., proton) imaging, abdomen; without contrast
material(s), followed by with contrast material(s) and further sequences (74183). You say that an MRI is
medically necessary. The Plan denied your request. The Plan says that further imaging cannot be approved
without knowing the outcome of the prior approved study.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve magnetic resonance (e.g., proton)
imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences
(74183). Our reviewer says that the MRI is medically necessary. Our physician reviewer found MRI abdomen
is medically necessary in this case to evaluate the renal mass that was incidentally discovered on non-contrast
spine CT. The enrollee has an allergy to radiographic contrast and MRI of the abdomen is an acceptable
imaging study to determine whether this lesion is malignant or benign. A prior pelvic MRI will not change the
necessity of performing an abdominal MRI.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of magnetic resonance (e.g., proton) imaging, abdomen; without contrast
material(s), followed by with contrast material(s) and further sequences (74183) have been met. Therefore, we
decided that the Plan has to pre-approve an abdominal MRI.
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.