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

We decided that the Plan does not have to pay for the dental services rendered on December 21, 2020.

You asked the Plan to pay for these services. You say that the services were covered under your employer coverage. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider.

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. The Plan covers these services when the services are medically necessary and reasonable. 

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 Our physician reviewer found. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the dental services rendered on December 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on September 28, 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 the LSO 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's chief complaint was arm pain. The enrollee also reported low back pain that radiates into his bilateral buttocks and posterior thighs. The LSO was not prescribed for one or more of the covered indications. The available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee.
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 lumbar-sacral orthosis (LSO) rendered on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse more for the oral exam (D0120) and the prophylaxis (D1110) provided on January 5, 2021.
You asked the Plan to reimburse more for the dental services. You say that you should have been reimbursed according to page 71 in the Evidence of Coverage book. You say that the check you received does not reflect that. The Plan denied your request. The Plan says there is a $30 copayment for preventive dental services including dental exams and prophylaxis. The Plan also says that if you receive services at an out of network provider, you are responsible for your copay and you may be responsible for difference between what the Plan reimburses the dentist and the charges billed by the provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and the services you received are listed as covered, dental services that you receive out of network may have higher cost share. The Evidence of Coverage clearly states that when you receive dental services out of network, you are responsible for your copay and you may be responsible for difference between what the Plan reimburses the dentist and the charges billed by the provider.
CPT Code     Billed Amount     Allowed Amount     Copay     Plan Paid     Your Responsibility
D0120           $49                    $35                       $30         $5                $44
D1110           $86                    $67                       $30         $37              $49
TOTAL:                                                                             $42              $93
Therefore, we decided that the Plan does not have to reimburse more for the oral exam (D0120) and the prophylaxis (D1110) provided on January 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Moxifloxacin eye drops.

You asked the Plan to pre-approve Moxifloxacin eye drops. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Moxifloxacin eye drops are not covered under the enrollee's Medicare Part B benefit.

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 Moxifloxacin eye drops.

Benefits for Moxifloxacin eye drops 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement provided on November 12, 2020.

You asked the Plan to pay for the full mouth debridement. You say that you believe these services should be covered. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.

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 full mouth debridement provided on November 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 documentation does not indicate that the enrollee requires services from the
LTACH that are not currently being provided. The documentation indicates that once the intravenous
antibiotics are completed, the enrollee could go to a SNF. The elements of the coverage rule are not
satisfied. The requested service is not 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for diagnostic mammography provided on December 11, 2020.

You asked the Plan to waive the coinsurance for diagnostic mammography. You say that mammograms should be covered in full. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.

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 diagnostic mammography. This mammography was provided due to a non-routine indication, so it is considered to be diagnostic mammography. The allowed amount of this claim is $217.02, resulting in a coinsurance obligation of $43.40. 

You have been asked to pay 20% coinsurance for diagnostic mammography. Diagnostic mammography falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 diagnostic mammography provided on December 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (82610, 82728, 83540, 84466) provided October 26, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the tests were ordered for screening purposes and 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 tests at issue in this appeal were requested 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 for lab services (82610, 82728, 83540, 84466) provided October 26, 2020.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.

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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to the current acute care facility with COVID pneumonia. She was treated with steroids, oxygen, and nebulizers. Recent notes show she is still requiring oxygen and nightly BiPAP, however, able to eat and vitals otherwise stable. The enrollee appears to be more stable and improving but requires additional short term acute care services to further stabilize. Long term acute care does not appear to be needed. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. 

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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventative procedure (D1999), two porcelain/ceramic retainer crowns (D6740), two core buildups (D2950) and one porcelain/ceramic pontic (D6245) provided on December 16, 2020.

You asked the Plan to pay for the dental services. You say that the Plan directed you to an in-network provider at a facility, but when you arrived for your appointment another provider performed the services. You did not realize that this provider was out-of-network. The Plan denied your request. The Plan says they will make a one-time exception for some services and cover them due to a misunderstanding and because the provider in question's contract started shortly after the date of service. However, some services will not be covered because they are not listed as covered benefits under your dental plan, regardless of who provides the care.

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 unspecified preventative procedure (D1999), two porcelain/ceramic retainer crowns (D6740), two core buildups (D2950) and one porcelain/ceramic pontic (D6245) provided on December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (DME) defined by code (K0553) provided to the enrollee on December 1, 2020.

You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. 

The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) defined by code (K0553) provided to the enrollee on December 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for altered mental status, cardiac arrest and respiratory failure. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in 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. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the chest.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says follow-up with chest x-rays is recommended.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found you have a chronic cough, with a normal CXR several months ago. PFTs have not been done. There is no clear indication for the requested CT scan at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the chest.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from May 11, 2020, to June 27, 2020.

You asked the Plan to waive the copayment for SNF care. You say that you were not advised that there would be a charge of $160 per day. You also say that you were told this charge was paid in full. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $0 copayment per day for days 1 to 20, a $160 copayment per day for days 21 to 51, and a $0 copayment for additional Medicare-covered days, up to 100 days for Skilled Nursing Facility (SNF) Care up to an in-network maximum out-of-pocket amount of $4,900 for 2020. At the time this claim was processed, $993.25 of the $4,900 in-network maximum out-of-pocket amount had been met. This SNF stay lasted 47 days, which were days 1 to 47 of the benefit period, resulting in a total copayment amount of $3,906.75 because this amount, along with other cost-sharing amounts you have been asked to pay, met the $4,900 in-network maximum out-of-pocket amount for 2020. 

You have been asked to pay a $0 copayment per day for days 1 to 20, a $160 copayment per day for days 21 to 51, and a $0 copayment for additional Medicare-covered days, up to 100 days for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the SNF care provided from May 11, 2020, to June 27, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has osteoporosis. She has not tried and failed the Plan's required drug, zoledronic acid. The records do not show that the required drug would be contraindicated or less effective; therefore, Prolia is not reasonable or 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 pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you will not be able to take care of yourself, and the IRF will be a great option for you to get the care you need. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require 15 hours per week of rehabilitation services and regular physician evaluation. Your care needs can be met at a lower level of care such as skilled nursing facility or sub-acute rehabilitation. 

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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Aminolevulinic acid, 10% gel (J7345)
provided December 28, 2020.

You asked the Plan to waive the coinsurance for the Aminolevulinic acid. You say that you were charged for
applying cream to your arms as part of the procedure that you were advised would be free. You are not being
billed as though applying the cream was not part of the procedure. The Plan denied your request. The Plan says
this claim was processed, and the correct cost share was applied per the Evidence of Coverage.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare Part B prescription drugs for Medicare Part B prescription drugs.

You have been asked to pay $61.20 for the Aminolevulinic acid. The Aminolevulinic acid 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 Aminolevulinic acid, 10% gel (J7345) provided December 28, 2020.