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

We decided that the Plan does not have to waive the copayment for scanning computerized ophthalmic diagnostic imaging (92133x2) and corneal pachymetry (76514).

You asked the Plan to waive the copayment for the diagnostic services. You say that you are appealing the decision as you had paid two $40 copayments, per the attached, and you received an EOB from the plan stating that you owe $0. The Plan denied your request. The Plan says this claim was processed and the correct copayment applied per the Evidence of Coverage.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $50 copay for each covered X-ray and $85 for each covered diagnostic procedure, or test at a network doctor's office for outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay $76.59 ($32.71 + $32.71 + $11.17) for the diagnostic services. Since the Medicare
allowable was less than the copay, the lesser amount is your responsibility. The diagnostic services fall 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 scanning computerized ophthalmic diagnostic imaging (92133x2) and corneal
pachymetry (76514).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services rendered from June 4, 2020 to September 21, 2020.

You asked the Plan to pay for these services. You say that you would like reimbursement. The Plan denied your request. The Plan says services from an out-of-network provider 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. The Plan contract says that enrollees must pay 100% for supplemental dental benefits from an out-of-network provider. 

We looked at the file and the Plan's rules. The file shows that the services were rendered by an out-of-network pprovider. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the dental services rendered from June 4, 2020 to September 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Computed Tomography (CT) scan of the abdomen and pelvis.

You asked the Plan to waive the copayment for the CT scan. You say that you believe this charge is a billing error. The Plan denied your request. The Plan says the claim processed 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 $215 copayment for diagnostic radiology services provided in the outpatient department of a network hospital or facility.

You have been asked to pay a $215 copayment for the CT scan. A CT scan is classified as a diagnostic radiology (diagnostic imaging) procedure. 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 Computed Tomography (CT) scan of the abdomen and pelvis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee was admitted to acute hospital for acute respiratory failure secondary to
bilateral pneumonia and Covid-19. The enrollee has not required prolonged mechanical ventilation. The
enrollee is on high flow oxygen via Vapotherm. The enrollee does not require services at the LTACH that are
not available at the acute care hospital where the enrollee is currently receiving care. There are no services
available at the LTACH that the enrollee requires that are not available at the health care setting being offered
by the health plan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not
available at the health care setting being offered by the health plan. The requested LTACH services are not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be
furnished safely and effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CRESEMBA Cap 186 Mg.
You asked the Plan to pre-approve CRESEMBA Cap. You say that the item is medically necessary. The Plan
denied your request. The Plan says your Medicare Advantage (MA) plan does not cover outpatient prescription
drugs.
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 CRESEMBA Cap 186 Mg.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. You say that the medically necessary services were provided
in good faith. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 provider in this case is not a network provider with the Plan. The Plan had network providers available to
provide the services at issue in this appeal. 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 the medical services provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Colchicine.

You asked the Plan to pre-approve Colchicine. You say that the enrollee remains stable on Colchicine. The
Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription
drugs.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Colchicine.

Benefits for Colchicine 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Interspinous and/or interlaminar device (22869, 22870).

You asked the Plan to pre-approve a Vertiflex Interspinous and/or interlaminar device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.

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 Vertiflex Interspinous and/or interlaminar device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy. 

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 Vertiflex Interspinous and/or interlaminar device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Interspinous and/or interlaminar device (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206).

You asked the Plan to pay for the dental services. You say that due to the condition of your teeth you have had your teeth cleaned and fluoride treatment done every 4 months for many years in an effort to keep your remaining teeth. The Plan denied your request. The Plan says this service exceeds the frequency limitation of the plan benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The health plan contract says that only 2 fluoride treatments are covered per plan year. The records show that you received this service.

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 at this time. Therefore, we decided that the Plan does not have to pay for topical application of fluoride varnish (D1206).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement of a crown (D2920) and the periodontal scaling and root planing (D4341) for all 4 quadrants provided from October 5, 2020, to October 19, 2020.

You asked the Plan to pay for the dental services. You say that you called the plan to get a list of in network providers. You say that you made an appointment and assumed that since the provider took your insurance, they were aware of your benefits. You also say that you were told by the dentist office that the services were covered by your insurance. The Plan denied your request. The Plan says re-cement of a crown is not listed as a covered service. The Plan says that periodontal scaling and root planing is not listed as a covered service. The Plan also says that when you called to get a list of in network provider, no benefits were discussed.

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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-cement of a crown (D2920) and the periodontal scaling and root planing (D4341) for all 4 quadrants provided from October 5, 2020, to October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chiropractic services provided a participating provider.

You asked the Plan to waive the copayment for chiropractic services. You say that you do not agree with these
copayments. The Plan denied your request. The Plan says the correct copayments have 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 $20
copayment for chiropractic services.

You have been asked to pay a $20 copayment for each chiropractic service. The total amount you are being
asked to pay is $240 ($40 x 12 visits = $240). Chiropractic services falls within the chiropractic 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 copayment for chiropractic services provided by a
participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99212) provided on October 16,
2020, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that your physicians are hospital based. You rely on the
hospital to obtain all necessary paperwork including authorization numbers and referrals forms. The Plan
denied your request. The Plan says enrollee's must receive their medical services from an in-network provider
with the exception being urgent or emergent services. Non-emergent services with non-contracted providers
require prior authorization before services being rendered.

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 had network providers
available who could have provided 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 outpatient office visit (99212) provided on
October 16, 2020, by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lateral branch radiofrequency ablation.

You asked the Plan to pre-approve lateral branch radiofrequency ablation. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

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 lateral branch radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain. The enrollee is status post L5-S1 fusion. There is a new pars defect noted as well as screw fracture. The enrollee had a spinal cord stimulator placed in 2018 but it does not cover the enrollee's pain and the enrollee has not had any attempt at re-programming. The enrollee is taking Cymbalta, Gabapentin, Robaxin, Naproxen, and Tramadol. The enrollee also uses marijuana. The enrollee had a sacroiliac joint injection, which gave the enrollee significant pain relief. The enrollee has several probable pain generators and has also not had a trial of spinal cord stimulator re-programming. The request for radiofrequency ablation of the lateral sacral branches, which is considered experimental/investigational. Therefore, the enrollee does not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lateral branch radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve lateral branch radiofrequency ablation.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member has no skilled therapy or skilled nursing service needs.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport (A0425, A0427)
provided November 10, 2020.

You asked the Plan to waive the copayment for the ambulance transport. You say that you believe you did not
need the ambulance and shouldn't have to pay the copayment for it. 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 $250
copayment for Ambulance services.

You have been asked to pay a $250 copayment for the ambulance transport. This service 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 copayment for the ambulance
transport (A0425, A0427) provided November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on October 8, 2020.

You asked the Plan to waive the coinsurance for an injection. You say that you've never had a copayment for this before. The Plan denied your request. The Plan says the correct 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 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $62.73. The total amount you are being asked to pay is $12.55 ($62.73 x 20% = $12.55). An 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 coinsurance for an injection provided by a participating provider on October 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for Magnetic Resonance Imaging (MRI). You say that the service provided was medically necessary. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 had network providers available who could have provided 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 by an out of network (OON) provider.