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

We decided that the Plan does not have to pre-approve a facet joint injection to be provided by an out-of-network
(OON) provider.

You asked the Plan to pre-approve a facet joint injection. You say that you do not want to go to a different
provider. The Plan denied your request. The Plan says there are in-network providers available for these
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 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
a facet joint injection to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid.

You asked the Plan to pay for the hearing aid. The Plan denied your request. The Plan says this provider is not in the vendor network.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are provided through the Plan's hearing vendor.

We looked at the file and the Plan's rules. The records show that the hearing aid was received from a provider who is not in the Plan's vendor network. Out-of-network hearing aids are not covered. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient visit.

You asked the Plan to waive the copayment for the outpatient visit. You say that this appointment was in relation to a previous surgery therefore a copayment should not apply. The Plan denied your request. The Plan says the postoperative time frame that applies to payment for each surgical procedure is 90 days. This appointment is beyond the 90-day time frame for 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 a $50 copayment for physician/practitioner services, including doctor's office visits (specialist visits). 

You have been asked to pay a $50 copayment for the outpatient visit. This outpatient visit falls within the physician/practitioner services, including doctor's office visits 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 outpatient visit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zovirax Ointment.

You asked the Plan to pre-approve Zovirax Ointment. You say that you want the enrollee treated with this
drug. The Plan denied your request. The Plan says this drug is 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 Zovirax Ointment.

Benefits for Zovirax Ointment 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of the breast (76641).

You asked the Plan to waive the copayment for the ultrasound. You say that you should not have to pay the copayment because no one informed you that there was one. The Plan denied your request. The Plan says the copayment was 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 $110 copayment for each Medicare-covered radiological diagnostic service, not including X-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic).

You have been asked to pay a $110 copayment for the ultrasound. This service 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 copayment for the ultrasound of the breast (76641).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services (80061, 84443, 80053, 85025).

You asked the Plan to waive the copayment for the lab services. You say that the tests were for an annual wellness exam and the copayment should be waived. The Plan denied your request. The Plan says lab services are not included in the annual wellness visit. The correct copayment was 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 $15 copayment for lab services.

You have been asked to pay a $15 copayment for the lab services. 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 lab services (80061, 84443, 80053, 85025).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction services (90215).

You asked the Plan to pay for the refraction services. You say that the enrollee contacted you and said her primary care physician had done a referral to the plan for her exam. You did not get a copy of the referral from her PCP. The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when received from an in-network provider.

We looked at the file and the Plan's rules. enrollee's must receive their vision services from an in-network provider. Based on this information, we decided that the Plan's rules for coverage of the refraction services have not been met. Therefore, we decided that the Plan does not have to pay for the refraction services (90215).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, bitewings, prophylaxis, and preventive procedure provided by an OON provider.

You asked the Plan to pay for the periodic oral evaluation, first intraoral periapical x-ray, bitewings, prophylaxis, and preventive procedure. You say that this provider has worked on your teeth for the past 30 years. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that no benefits are available for procedures performed by OON 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, bitewings, prophylaxis, and preventive procedure provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the services was not filed until September 14, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SPECT scan and coinsurance for an injection provided by a participating provider.

You asked the Plan to waive the copayment and coinsurance for a SPECT scan and injection. You say that you were told that this would be covered by your insurance and you were told nothing was due. The Plan denied your request. The Plan says the correct copayment and coinsurance 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 $200 copayment and a 20% coinsurance for outpatient diagnostic tests/SPECT scan and Medicare Part B prescription drugs.

You have been asked to pay a $200 copayment for a SPECT scan and a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $236.70. The amount you are being asked to pay for an injection is $47.34 ($236.70 x 20% = $47.34). The total amount you are being asked to pay is $247.34 ($200 + $47.34 = $247.34). A SPECT scan falls within the outpatient diagnostic tests/SPECT scan benefit category and 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 copayment for a SPECT scan and coinsurance for an injection provided by a participating provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hospital swing bed stay, a skilled nursing facility
(SNF) level of care.

You asked the Plan to pre-approve the swing bed stay. You say that the enrollee would benefit from short-term
daily therapy services. The Plan denied your request. The Plan says the enrollee is medically stable and does
not need daily therapy.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 swing bed stay. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 94-year-old
female with falls, dementia, chronic kidney disease, atrial fibrillation and a pacemaker. From a nursing
perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. Her lungs were
clear. Regarding rehabilitation services, the beneficiary received physical therapy. The beneficiary was at
contact guard to minimal assist level with functional mobility including gait to 150 feet with a rolling walker.

There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs;
however, these do not require daily skilled therapy services. This beneficiary does not meet severity of illness
or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the swing bed stay have not been met. Therefore, we decided that the Plan does
not have to pre-approve a hospital swing bed stay, a skilled nursing facility (SNF) level of care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network
provider.

You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says
members must receive care from a network provider and in most cases care received from an out-of-network
provider (a provider who is not part of our Plan's network) will not be covered, except for emergency care or
urgently needed service and needed medical care that Medicare requires our plan to cover and the providers in
our network cannot provide this care (authorization is required).

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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve
physician's services to be provided by the out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483).

You asked the Plan to pay for the drug testing. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the CPT code billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code G0483 is Drug test(s), definitive, 22 or more classes.

We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not
support that the sample was tested for 22 or more classes of drugs. Based on this information, we decided that
Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not
have to pay for drug testing (G0483).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider.

You asked the Plan to waive the copayment for specialist services. You say that you do not know why this is being denied. The Plan denied your request. The Plan says these services were not denied. The Plan says that 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 $10 copayment for physician/practitioner services/in-network/specialist's office visit.

You have been asked to pay a $10 copayment for specialist services. The correct copayment has been applied to the services that were provided. Specialist services falls within the physician/practitioner services/in-network/specialist's office visit 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 specialist services provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the excision of a benign lesion of up to 1.25 centimeters (D7410).

You asked the Plan to pay for the limited oral evaluation and excision of a benign lesion. You say that the services should be covered. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan says that the frequency limit for this service has been exceeded. The Plan also says that the excision of a benign lesion is not listed as a covered service.

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 frequency limit of 1 limited oral evaluation per plan year has been exceeded. The record shows that the Plan paid for a limited oral evaluation. Additionally, the excision of a benign lesion is not among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the excision of a benign lesion of up to 1.25 centimeters (D7410).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5130).

You asked the Plan to pay for the hearing aids. You say that the hearing aids were medically necessary. The Plan denied your request. The Plan says hearing services obtained out-of-network are not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when obtained from a plan-contracted vendor.

We looked at the file and the Plan's rules. The hearing aids were obtained from a non-contracted vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5130).
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical condition is not complex and does not require close supervision by a rehabilitation doctor.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for osteomyelitis of the great toe with treatment including antibiotics and amputation of the great toe. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you don not agree with the copayment. The Plan denied your request. The Plan says the copayment was 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 $325 copayment per day, days 1 to 5 of an inpatient hospital stay.

You have been asked to pay total of $1,625 ($325 copayment per day, days 1 to 5) for the inpatient hospital stay. This service falls within the Inpatient hospital 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 inpatient hospital stay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays.

You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you would like these services to be covered. The Plan denied your request. The Plan says your benefits for these services have been satisfied and the frequency limitations have been exceeded.

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 is limited to one procedure every three years and full mouth or panoramic x-rays are limited to one procedure every five years. The record shows that you received a comprehensive oral evaluation and complete series of intraoral x-rays, and your comprehensive oral evaluation and full mouth or panoramic x-rays benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays.