Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on January 10, 2021.
You asked the Plan to waive the copayment for emergency care. You say that the provider could not treat your condition and did nothing but recommend another emergency room facility. 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 copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay an $80 copayment for emergency care. The record shows that you received emergency care on January 10, 2021. Therefore, you are responsible to pay the $80 copayment. You have been asked to pay an $80 copayment 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 copayment for emergency care provided on January 10, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve reimplantation of a left breast implant.

You asked the Plan to pre-approve reimplantation procedure. You say that you are appealing this denial. The Plan denied your request. The Plan says that the denial of authorization for this procedure is correct, because reimplantation would be considered cosmetic.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 reimplantation procedure. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found you had a breast implant roughly 15 years ago. Physical examination demonstrated contracture. The imaging demonstrates calcifications and extra capsular leakage of silicone. This breast reimplantation would be reconstructive surgery as defined by Medicare rules and is 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 reimplantation procedure have been met. Therefore, we decided that the Plan has to pre-approve reimplantation of a left breast implant.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: 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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the patient does not require treatment by multiple therapies and there are no complex nursing or rehabilitation 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 IRF care have not been met. Specifically, medically necessary services are available at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554, K0553).

You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee needs this to make sure she does not crash. The Plan denied your request. The Plan says the requirements for coverage have not been met.

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 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. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554, K0553).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for office visits (99213, 99214) and destruction of 15 or more premalignant skin growths (17004) provided February 1, 2021, to March 1, 2021.
You asked the Plan to waive the copayment for office visits and destruction of 15 or more premalignant skin growths. You say that you feel that you should not have to pay a copayment as this an ongoing procedure. The Plan denied your request. The Plan says the copayment has processed correctly, and no reimbursement is due.
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 $25 copayment for Medicare-covered specialist visits. You have been asked to pay a total cost share of $100 for the office visits and destruction of 15 or more premalignant skin growths ($25 copayment x 4 dates of service).
These services fall within the Medicare-covered specialist 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 office visits (99213, 99214) and destruction of 15 or more premalignant skin growths (17004) provided February 1, 2021, to March 1, 2021.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve continued home health services.

You asked the Plan to pre-approve continued home health services. You say that the requested continuation of home health services is medically necessary. The Plan denied your request. The Plan says that the requested continuation of home health services is not medically necessary.

The Plan must follow Medicare rules. The rules say that a NOMNC must be issued prior to discontinuing coverage of home care services. 

There is no evidence that a NOMNC has been issued saying that coverage is ending for the home care services at issue in this appeal. Therefore, we decided that the Plan has to pre-approve continued home health services.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the mattress pad, knee brace, walker, commode, and knee exerciser provided on December 7, 2020.

You asked the Plan to waive the coinsurance for the mattress pad, knee brace, walker, commode, and knee exerciser. You say that you were told these supplies were covered by insurance as mandatory for your recovery. You say that you never expected a bill, and the charges should be covered. The Plan denied your request. The Plan says the coinsurance applied correctly.

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 20% coinsurance for Medicare-covered items from an in-network provider.

You have been asked to pay a total of $278.87 for the mattress pad, knee brace, walker, commode, and knee exerciser.

TOTAL:
$278.87

The mattress pad, knee brace, walker, commode, and knee exerciser fall within the "Durable medical equipment (DME) and related 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 the mattress pad, knee brace, walker, commode, and knee exerciser provided on December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), first intraoral periapical x-ray (D0220), two additional intraoral periapical x-rays (D0230 x2), bitewing x-rays (D0274), prophylaxis (D1110), topical application of fluoride, excluding varnish (D1208), crown (D2740), core buildup, including any pins when required (D2950), and four resin-based composites (D2332 x4) provided from January 12, 2021, to January 21, 2021 by an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation, intraoral periapical x-ray, bitewing x-rays, prophylaxis, topical application of fluoride, crown, core buildup, and resin-based composites. You say that this treating provider was on the Plan's list of in-network providers. You also say that the provider's office contacted the Plan and confirmed they were in-network. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that the call records were checked, and there is no record of yourself or the provider's office contacting the Plan prior to the January 12, 2021, or January 21, 2021 dates of 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 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 comprehensive oral evaluation (D0150), first intraoral periapical x-ray (D0220), two additional intraoral periapical x-rays (D0230 x2), bitewing x-rays (D0274), prophylaxis (D1110), topical application of fluoride, excluding varnish (D1208), crown (D2740), core buildup, including any pins when required (D2950), and four resin-based composites (D2332 x4) provided from January 12, 2021, to January 21, 2021 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from December 8, 2020, to December 10, 2020.

You asked the Plan to pay for the self-administered drugs. You say that you would like to appeal these drugs. The Plan denied your request. The Plan says these services are not covered.

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 pay for the self-administered drugs provided from December 8, 2020, to December 10, 2020.

Benefits for the self-administered drugs 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 reimburse you for turmeric and ginger supplements provided by on February 28, 2021.

You asked the Plan to reimburse you for the turmeric and ginger supplements. You say that you are unable to take NSAIDs due to stomach issues and you thought you could use Pick Your Perks to help with the cost of the supplements. The Plan denied your request. The Plan says the supplements are not eligible for coverage under the Pick Your Perks program.

The Plan contract says that the over-the-counter items must be included on the Plan's allowed items list. 

We looked at the file and Medicare rules. The file shows that the supplements are not on the Plan's allowed items list and are ineligible for coverage. Therefore, we decided that the Plan does not have to reimburse you for turmeric and ginger supplements provided on February 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays and periodontal scaling and root planing provided on January 21, 2021.

You asked the Plan to pay for the complete series of intraoral x-rays and periodontal scaling and root planing. You say that you believe you received a regular cleaning. You also say that the provider took a lot of x-rays. The Plan denied your request. The Plan says the complete series of intraoral x-rays is not a covered service. The Plan also says that your benefits for the periodontal scaling and root planing of the upper left quadrant have been satisfied and the frequency limitation has 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, complete series of intraoral x-rays is not among those covered under this benefit. The Plan contract says that periodontal scaling and root planing is limited to one procedure code per quadrant every three years the record shows that you received a periodontal scaling and root planing on the upper left quadrant on May 21, 2019, and your periodontal scaling and root planing benefit for the upper right quadrant has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays and periodontal scaling and root planing provided on January 21, 2021.
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 IRF care is necessary for you as you will require multiple therapies and care for several medical conditions. The Plan denied your request. The Plan says the records show that you do not require an intensive team in order to reach functional rehab goals. Other settings would be appropriate for care.
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical conditions are stable. There is no documented need for an intensive rehabilitation program. Medically necessary services 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the mandibular partial denture provided on February
11, 2021.

The enrollee asked the Plan to pay more for the mandibular partial denture. The enrollee says that she received
a predetermination stating she would owe nothing for the dentures. The Plan denied the enrollee's request. The
Plan says the enrollee's dental maximum has been met. The Plan also says that the predetermination states that
benefits will be subject to the deductible and plan maximums at the time the services are rendered.

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 an annual maximum
benefit of $1,000 every year. The record shows that the enrollee met the annual maximum benefit while
processing this claim for the February 11, 2021, date of service and the enrollee's annual maximum benefit has
been exhausted. Therefore, we decided that the Plan does not have to pay more for the mandibular partial
denture provided on February 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the seven extractions (D7210 x7) and alveoloplasty in
conjunction with extractions (D7311) provided on February 5, 2021.
You asked the Plan to pay for the extractions and alveoloplasty. You say that this surgery was medically
needed before you could have an aortic heart valve replacement. The Plan denied your request. The Plan says
these services are not covered under Medicare.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. The record shows that the tooth extractions were due to an aortic heart
valve replacement, and not for radiation treatments for neoplastic cancer disease. Therefore, we decided that
the Plan does not have to pay for the seven extractions (D7210 x7) and alveoloplasty in conjunction with
extractions (D7311) provided on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services and subsequent hospital care services provided from August 20, 2019 to September 5, 2019.

You asked the Plan to pay for the critical care services and subsequent hospital care services. You say that the claims were filed timely. The Plan denied your request. The Plan says the claims were untimely.

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 critical care services and subsequent hospital care services was not filed until January 15, 2021. 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 critical care services and subsequent hospital care services provided from August 20, 2019 to September 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate maxillary denture, immediate mandibular partial denture, eight simple extractions, five surgical extractions, and removable prosthodontic procedure provided on October 8, 2020.

You asked the Plan to pay for the immediate maxillary denture, immediate mandibular partial denture, extractions, and removable prosthodontic procedure. You say that the enrollee was advised that their insurance would cover these services. The Plan denied your request. The Plan says these services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the immediate maxillary denture, immediate mandibular partial denture, eight simple extractions, five surgical extractions, and removable prosthodontic procedure provided on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 26, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for the office visit provided on October 26, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay the new claim for the flexible keel foot provided on September 28, 2020.

You asked the Plan to pay for all lower extremity prostheses, foot, flexible keel (L5972). You say that the flexible keel foot was denied. The Plan denied your request. The Plan says this is a duplicate claim, the flexible keel foot was paid for.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. The records show the flexible keel foot (L5972) was paid for on October 28, 2020. Therefore, we decided that the Plan does not have to pay the new claim for the flexible keel foot provided on September 28, 2020.