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

 
We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on 
November 1, 2018. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were not aware of 
the time limit to file for the claim. You also say that you would like to be reimbursed for these services. The 
Plan denied your request. The Plan says the claim was submitted beyond the one-year timely filing 
requirements. 
 
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 periodic oral evaluation and prophylaxis was not filed until November 
21, 2019. 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 periodic oral evaluation and prophylaxis 
provided on November 1, 2018.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on June 2, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the home visit. You say that you would like this claim to be reprocessed for 
payment. The Plan denied your request. The Plan says the service was rendered by a non-network provider. 
The Plan also says that the services were not referred by a network provider, nor were they approved in 
advance. 
 
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 home visit provided on June 2, 2020 by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) and bone graft for ridge 
preservation (D7953) provided on July 17, 2020. 
 
You asked the Plan to pay for the dental service. You say that you had to have surgery due to an infected root 
canal. You say that if you did not have the surgery, you would have become septic. You also say that you feel 
that this was more of a medical procedures than just a dental procedure. The Plan denied your request. The Plan 
says the services you received are dental in nature. The Plan also says that the surgical extraction is not listed as 
a covered service. The Plan says the bone graft is not listed as a covered service either. 
 
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 
surgical extraction (D7210) and bone graft for ridge preservation (D7953) provided on July 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dermatology services rendered. 
 
You asked the Plan to pay for these services. You say that the doctor did not make it clear that the services 
wouldn't be covered. The Plan denied your request. The Plan says the provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
dermatology services rendered.
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 that you are not ready to go home. The Plan denied 
your request. The Plan says that you can safely receive the services you need in other settings. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a 
lower level of care. Our physician reviewer found that your 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation facility (IRF) services provided on March 2, 2020, through March 17, 2020.

You asked the Plan to waive the copayment for IRF services. You say that the hospital stay was a continuation of stay at a different hospital so services should be covered. The Plan denied your request. The Plan says the cost share 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $370 copayment each day for days one to five for inpatient hospital care. For inpatient hospital care, the cost-sharing is applied each time you are admitted to a hospital. A transfer to a separate facility type (such as an inpatient IRF or LTCH) is considered a new admission. 

The enrollee has been asked to pay a $370 copayment each day for days one to 5 for IRF services. IRF services falls within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan ($370 x 5 = $1850). This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient rehabilitation facility (IRF) services provided on March 2, 2020, through March 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the requested services. You say that you need tooth #14 pulled as soon as 
possible. The Plan denied your request. The Plan says dental services performed by an oral surgeon 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.  
 
We looked at the file, and Medicare rules. Dental services are covered when performed by a participating 
general dentist. Based on this information, we decided that the Plan's rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve dental services to be provided by an oral 
surgeon.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance services (A0428 and A0425) 
provided on August 8, 2020. 
 
You asked the Plan to pay for the non-emergent ambulance services. You say that you would like 
reconsideration because this was the only transportation available at this hour. The Plan denied your request. 
The Plan says this service is not appropriate for the diagnosis billed. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 the non-emergent ambulance services. Our 
reviewer says that the documentation does not support that another means of transport was contraindicated. Our 
physician reviewer found the documentation does not support that you needed the expertise, services and 
lifesaving and life-sustaining equipment that only a fully-equipped ambulance could provide for safe transport. 
 
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 non-emergent ambulance services have not been met. Therefore, we decided 
that the Plan does not have to pay for the non-emergent ambulance services (A0428 and A0425) provided on 
August 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on 
September 28, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you thought that the 
injection was fully covered and disagree with the charges. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received a Medicare Part B drug on September 28, 2020. The allowed amount is $1,863.53 and 20% of 
that is $372.71.  
 
You have been asked to pay the total coinsurance amount of $372.71 for a Medicare Part B drug. A Medicare 
Part B drug 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 a Medicare Part B drug provided on September 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you disagree with the denial.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 enrollee was admitted to the hospital after a fall on January 31, 2021. He underwent hip surgery on February 1, 2021. He needs assistance with bed mobility, toilet transfers, grooming, and ambulating 56 feet with a walker and oxygen. The complexity of his nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. His medical needs are stable. While he may benefit from further therapy, he does 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the medical supplies provided from March 6, 2020, through September 8, 2020.
You asked the Plan to waive the coinsurance for the medical supplies. You say that you were provided with a Home INR Testing Device and materials, and that this device is not rented or owned by you, and that the provider retains ownership. You state that this service is being billed as "outpatient hospital service" rather than durable medical equipment (DME), and therefore, should not be billed for DME. The Plan denied your request. The Plan says the claims were processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Please be advised that you are not being assessed coinsurance for DME, and that you are being assessed a coinsurance for medical supply. Per your benefits in the 2020 Evidence of Coverage, you are responsible for 20% coinsurance for each Medicare-covered medical supply. You received the Medicare-covered medical supplies; therefore, you are responsible for the 20% coinsurance assessed. 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 medical supplies provided from March 6, 2020, through September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit with a specialist (99212) 
provided on September 3, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not owe a 
copayment. The Plan denied your request. The Plan says office visits with a specialist have a $50 copayment. 
 
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 provided by a specialist.  
 
You have been asked to pay a $43 copayment for a specialist office visit. A specialist office visit falls within 
the Physician/Practitioner services benefit category and is subject to a $50 copayment. You have been asked to 
pay an amount that is equal to or less than the required copay. 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 office visit with a specialist (99212) provided on September 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is 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 considered medically reasonable and necessary based on Medicare guidelines. 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 mental status changes, seizure, sepsis and a urinary tract infection. Medical conditions are 
stable. There are no medical needs requiring inpatient admission. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit provided on August 5, 2020.You asked the Plan to pay for the outpatient visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.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 an outpatient visit provided on August 5, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not have to pre-approvegammagard (J1569).You asked the Planto pre-approvegammagard. You say that this is medically necessary.The Plandenied your request. The Plansays coverage of this medication is the responsibility of the enrollee's prescription drug plan.The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the enrollee's home for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve gammagard (J1569).Benefits for gammagardmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lead wires provided on September 20, 2020.You asked the Plan to pay forthe lead wires. You say that you would like the plan to reconsider their denial.The Plandenied your request. The Plan says the items rendered are not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that replacement of lead wires (A4557) more often than every 12 months are non-covered.We looked at the file and Medicare rules. Review of the file shows that the enrollee received a Transcutaneous electrical nerve stimulation (TENS)unit and lead wires on May 20, 2020. Twelve (12) months had not passed since the enrollee last received lead wires. Based on this information, we decided that Medicare rules for coverage of the lead wires have not been met.Therefore, we decided that the Plan does not have to pay forthe lead wires provided on September 20, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Botox (J0585).
You asked the Plan to pre-approve Botox. You say that the services are necessary. The Plan denied your
request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 Botox. Our reviewer says that the
medication is medically necessary. Our physician reviewer found the review indicates that the enrollee has
tried and failed standard therapies for the treatment of her Raynauds. The documentation supports that the
Botox is medically reasonable and necessary for the enrollee. The documentation supports that the Botox is
safe and effective 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 Botox have been met. Therefore, we decided that the Plan has to pre-approve
Botox (J0585).
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.