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

 
We decided that the Plan does not have to pay for the periodontal scalings and root planings provided on 
December 12, 2019 to December 13, 2019. 
 
You asked the Plan to pay for the scalings and planings. You say that the Plan provided you with a few in-
network providers that you could receive dental care from. You also say that your provider called and 
confirmed their network status with the Plan. The Plan denied your request. The Plan says this service is not a 
covered 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 
periodontal scalings and root planings provided on December 12, 2019 to December 13, 2019.  
 
Your complaint about being disappointed with the Plan is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory and drug services provided on July 14, 2019 
by an out of network (OON) provider. 
 
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory and drug services provided on July 
14, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the DME purchased on March 26, 2020 from a non-Medicare provider.
You asked the Plan to pay for the DME. You say that you called prior to purchasing to ensure coverage and the gentleman in the office said it would be covered. The Plan denied your request. The Plan says review of the previous customer service calls confirmed you were advised that authorization would need to be obtained and Medicare guidelines would need to be followed in order for the services to be covered. The Plan states the items were obtained from a provider who is not under contract with the health plan and is not certified for Medicare.
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. Review of the file show that you purchased the DME on March 26, 2020 from a non-Medicare provider. The rules say that to receive payment for covered Medicare items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be enrolled in the Medicare program. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the DME purchased on March 26, 2020 from a non-Medicare provider.
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 need rehab. The Plan denied your request. The 
Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 medically necessary. Our physician reviewer found the submitted records show that 
you were admitted to the hospital on August 17, 2020 for spinal surgery. All your medical conditions are stable 
and you have no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You 
may benefit from further therapy but do not require an intensive therapy program in an IRF. 
 
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 waive the copayment for a CT scan provided on April 17, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that the Plan should pay for the CT scan. 
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 a $200 
copayment for advanced imaging services.  
 
You have been asked to pay the allowed amount of $180.15, which is less than the $200 copayment for a CT 
scan. A CT scan 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 a CT scan provided on April 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wireless capsule endoscopy.
You asked the Plan to pre-approve a wireless capsule endoscopy. You say that the enrollee has had longstanding abdominal pain of unclear etiology. You say that the enrollee had an extensive evaluation, including an EGD colonoscopy, an endoscopic ultrasound, and multiple imaging tests. You say that you have also sent off an extensive evaluation of laboratory evaluation. You say that, despite this significant evaluation, the enrollee continues to have ongoing unexplained abdominal pain. You say that you are concerned there is a small bowel pathology that has not been visualized endoscopically or with imaging. The Plan denied your request. The Plan says medical studies have not proven that the requested service is helpful for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a wireless capsule endoscopy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found chronic and subjective abdominal pain is not a covered indication per provided plan policy nor conventional community-accepted indications for wireless capsule endoscopy. Medical necessity for a plan-policy exception is not demonstrated by available records. No objective abdominal examination was provided at the enrollee's last office visit on July 6, 2020, nor was the review of systems remarkable aside for complaint of abdominal pain of unspecified location, intensity, or frequency We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a wireless capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a wireless capsule endoscopy.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for long term hospice care (T2046) provided on December 1, 
2019 through December 31, 2019. 
 
You asked the Plan to pay for the long term hospice care. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT code T2046 has a status indicator of I 
which is not valid for Medicare purposes. 
 
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 find that CPT code T2046 is not supported in the record. Specifically, per the physician fee schedule, CPT 
code T2046 has a status indicator of I. This means that CPT code T2046 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the long term hospice care have not 
been met. Therefore, we decided that the Plan does not have to pay for long term hospice care (T2046) 
provided on December 1, 2019 through December 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for TAVR (33999) provided on May 28, 2019. 
 
You asked the Plan to pay for the TAVR. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says this claim was not billed with a valid clinical trial 
number or modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 33999 is not supported in the record. Specifically, this claim was not billed with an 
appropriate clinical trial number. Additionally, this claim was not billed with the required Q0 modifier. Based 
on this information, we decided that Medicare rules for coverage of the TAVR have not been met. Therefore, 
we decided that the Plan does not have to pay for TAVR (33999) provided on May 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the spinal pump implantation procedure provided on March 5, 2020.
You asked the Plan to reduce the copayment for the spinal pump implantation procedure. You say that your previous insurance paid all but $50 for an outpatient procedure. You say you would like the insurance company to pay more. The Plan denied your request. The Plan says you have been charged 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 $150 copayment for Medicare-covered surgery or other services at an in-network outpatient hospital or an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical changes. You have been asked to pay a $150 copayment for the spinal pump implantation procedure. The spinal pump implantation procedure falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 reduce the copayment for the spinal pump implantation procedure provided on March 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the air ambulance transport provided on 
January 14, 2020. 
 
You asked the Plan to waive the coinsurance for the air ambulance transport. You say that you disagree with 
this charge because ground transportation was not available. The Plan denied your request. The Plan says you 
have been charged 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 20% 
coinsurance for each fixed wing, rotary, or water ambulance transport (one-way).  
 
You have been asked to pay $822.56 which is 20% of the allowed amount for the air ambulance transport. The 
allowed amount is $4,112.81. ($4,112.81 x 20% = $822.56). The air ambulance transport falls within the 
?Ambulance services? 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 air 
ambulance transport provided on January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 5, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for laboratory tests. You say that when the enrollee switched from Original
Medicare to this Plan you were expecting to get the same level of coverage. The Plan denied your request. The
Plan says the denial of payment for these services is correct, because this provider is out-of-network with the
Plan and the ordering provider is also out-of-network with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on March 5, 2020
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on February 26, 2020. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says the 
Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 
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 nurse practitioner services provided on February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic blood pressure monitor (A4670) provided
January 21, 2020.
You asked the Plan to pay for Automatic blood pressure monitor. You say that the billed supplies were not
delivered to the enrollee, they were used on the enrollee while on the unit.. The Plan denied your request. The
Plan says this service is not covered under Medicare.
The Plan must follow Medicare rules. Medicare rules say that oxygen and other items and services provided as
part of the transport are included in the fee schedule base payment rate and are not separately payable. Payment
for these items is included in the payment for the ambulance transport. Medicare does not allow for separate
billing of these services and supplies.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of Automatic blood pressure monitor have not been met. Therefore, we decided that the Plan does not
have to pay for the automatic blood pressure monitor (A4670) provided January 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Scopolamine patch and Oxycodone/Acetaminophen 
provided on October 1, 2019. 
 
You asked the Plan to pay for the Scopolamine patch and Oxycodone/Acetaminophen. You say that these drugs 
were not self-administered. You also say that you did not take these drugs on your own. The Plan denied your 
request. The Plan says these drugs are self-administered, and are not covered by Part B. 
 
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 Scopolamine patch and 
Oxycodone/Acetaminophen provided on October 1, 2019.  
 
Benefits for the Scopolamine patch and Oxycodone/Acetaminophen 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on February 25, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physician services provided on February 25, 
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device (PMD). 
 
You asked the Plan to pre-approve the PMD. You say that the documentation provided supports the need for 
the requested item. The Plan denied your request. The Plan says the notes provided do not say if the enrollee's 
activities or movement have been impaired. The Plan says that the notes do not say that a walker or cane have 
been unable to improve the enrollee's mobility. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 PMD. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the documentation does not support that 
the criteria of coverage have been met. The documentation indicates the enrollee has a personal mobility 
deficit, but does not indicate that it impairs participation in mobility-related activities of daily living in the 
home. The documentation does not indicate an objective evaluation of the upper extremities and function that 
reveal this mobility deficit cannot be ameliorated by a walker or a manual wheelchair, or that the enrollee can 
safely operate the PMD in the home. 
 
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 PMD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power mobility device (PMD).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says step therapy criteria 
have not been 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 Aranesp. Our reviewer says that 
Aranesp is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found 
that the enrollee has not trialed Retacrit. Step therapy, as outlined by the plan, requires this drug be trialed first. 
The documentation does not outline contraindications or reasons this medication was not considered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.