Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the diabetic shoe and insert provided on August 14, 2019.
You asked the Plan to waive the coinsurance for the diabetic shoe and insert. You say that shoes should be covered once per calendar year. You say that you can't pay for them. 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 copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for therapeutic custom molded shoes, including inserts provided with such shoes and two additional pairs of inserts, or one pair of depth shoes and three pairs of inserts. You have been asked to pay a total of $73.90 for the diabetic shoe and insert.
Date of Service
Equipment
Allowed Amount
Coinsurance
Member Liability
August 14, 2019
Diabetic Shoe
$130.74
20%
$26.15
August 14, 2019
Multiple Density Insert
$238.74
20%
$47.75
TOTAL:
$73.90
The diabetic shoe and insert fall within the "Diabetes self-management training, diabetic 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 coinsurance for the diabetic shoe and insert provided on August 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110), the comprehensive oral evaluation
(D0150), and the intraoral complete series of x-rays (D0210) provided on August 26, 2019.
You asked the Plan to pay for the dental services. You say that you were never told when you signed up for the
dental benefit that preventive services were not included. You say that you are in the process of changing her
dental insurance to include future routine dental services. You also say that the enrollee is on a fixed income
and does not have money to pay for this routine visit. The Plan denied your request. The Plan says the
prophylaxis, comprehensive oral evaluation, and intraoral complete series of x-ray are not covered services.
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
prophylaxis (D1110), the comprehensive oral evaluation (D0150), and the intraoral complete series of x-rays
(D0210) provided on August 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330), and the surgical extraction (D7210) provided on August 27, 2019.You asked the Plan to pay forthe dental services. You say that your extraction was an emergency. You say that you were ignorant of the extra insurance that your plan provided.The Plan denied your request. The Plan says panoramic x-ray is not listed as a covered service. The Plan also says that the surgical extraction is not listed as a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though thePlan 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 forthe panoramic x-ray (D0330), and the surgical extraction (D7210) provided on August 27, 2019.
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-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says the enrollee can receive the care required at the current facility they are in. Therefore, 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 the review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from May 17, 2019 through May 19, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. Therules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer saysthat the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expectedthat the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from May 17, 2019 through May 19, 2019.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 decideto open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvestab phlebectomy of varicose veins with vein ablation (37766, 36475).You asked the Plan to pre-approvestab phlebectomy of varicose veins with vein ablation. You say that the services are necessary.The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.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 stab phlebectomy of varicose veins with vein ablation. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has failed conservative treatment for painful varicose veins with documented venous reflux and would benefit from venous ablation.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of stab phlebectomy of varicose veins with vein ablation have been met.Therefore, we decided that the Plan has to pre-approvestab phlebectomy of varicose veins with vein ablation (37766, 36475).If the Plandoes 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 doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visual field exam provided on May 29, 2019.
You asked the Plan to waive the copayment for the visual field exam. You say that you had the same service last year and did not pay a copayment. 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 $30 copayment per specialist visit. You have been asked to pay a $30 copayment for the visual field exam. The visual field exam falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the visual field exam is considered an ophthalmological service.
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 visual field exam provided on May 29, 2019.
Our decision is only about the 2019 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on March 15, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This meansthat the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on March 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you have walking problems when walking without foot support.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral complete series of x-rays (D0210) provided on September 30, 2019.
You asked the Plan to pay for the dental service. You say that you were not aware there was a limit on the images. You also say that this is the first time you are being told there is a limit. The Plan denied your request. The Plan says the frequency limit 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, the frequency limit for the complete series of intraoral x-rays has been exceeded. Therefore, we decided that the Plan does not have to pay for the intraoral complete series of x-rays (D0210) provided on September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided by "the provider" from August 17, 2019 to November 5, 2019.You asked the Plan to pay fortest strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided by "the provider" from August 17, 2019 to November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on September 18, 2019.You asked the Plan to pay forthe outpatient services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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-approvethe servicesat 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 foroutpatient services provided on September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336, 1036F, 3008F, 3075F, 3075F, 3078F, 1160F) provided on July 19, 2019 by the out of network provider.
You asked the Plan to pay for a domiciliary or rest home visit. You say that this should be covered. The Plan denied your request. The Plan says these services were not authorized.
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 a domiciliary or rest home visit (99336, 1036F, 3008F, 3075F, 3075F, 3078F, 1160F) provided on July 19, 2019 by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET with CT scan (78815).You asked the Plan to pre-approvea PET with CT scan (78815). You say that the requested PET with CT scan is medically necessary.The Plan denied your request. The Plan says the requested PET with CT scan does not meet criteria.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 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 a PET with CT scan (78815). Our reviewer says that the requested PET with CT scan does not meet criteria. Our physician reviewer found the enrollee is with a history of head and neck cancer status post chemoradiation in 2017. The enrollee has not well documented enlarged neck nodes. This is a PET scan request to evaluate nodes.Based on the documentation provided, the enrollee does not meet Medicare criteria for the requested PET scan. Per Medicare guidelines, the request for a PET scan in this case is not approved as it is not for surveillance. The enrollee's nodes do not rise to the level of strong suspicion for recurrence thus Medicare criteria have not been met.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 PET with CT scan (78815)have not been met.Therefore, we decided that the Plan does not have to pre-approvea PET with CT scan (78815).
Appeal type: Drugs
Decision: Favorable

We decided that the Planhasto pre-approveEvenity injections.You asked the Planto pre-approvethe Evenity injections. You say that this drug is needed.The Plandenied your request. The Plansaysthatthisdrug is not covered by the plan. The Plan will cover other drugs instead.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. Medicare also requires plans to clearly disclose any limitations or condition related tocoverage.Medicare now allows plans to implement step therapy in which they may require a trial of a preferred drug before allowing coverage of a requested drug. However, Medicare rules have clearly indicated that this can only be implemented if the contract clearly discloses this information in the Medicare Part B drug section of the contract. The contract provided has no such disclosure. As such, we are not able to validate the step therapy argument made by the Plan.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 Evenity injections. Our reviewer says that the requested medication is considered medically reasonable and necessary. Our physician reviewer found theenrollee has findings of osteoporosis with documented trial and failure of Actonel and Fosamax. The requested drug is considered safe and effective. There are other drugs which could be considered medically necessary; however, the step therapy requirement is not adequately disclosed.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 Evenity injections have been met.Therefore, we decided that the Planhas to pre-approveEvenity injections
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. You say that the Plan has assisted you with coverage of the requested supplies in the past. You also say that medicine is responsible for the need of the incontinence supplies. The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 3 additional retainer crowns (D6750) provided on June 20, 2019.You asked the Plan to pay for 3 additional retainer crowns. You say that you fell and broke your teeth. You say that the services were not cosmetic. You also say that you needed the services so that you could eat and chew food.The Plandenied your request. The Plan says the frequency limit of 2 crowns per calendar year 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 and retainer crowns are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for 2 of the retainer crowns that you received on June 20, 2019.Therefore, we decided that the Plan does not have to pay forthe 3 additional retainer crowns (D6750) provided on June 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bitewing x-rays (D0272), prophylaxis (D1110), and the periodic oral evaluation (D0120) provided on October 21, 2019.You asked the Plan to pay forthe dental services. You say that the provider advised that he had not opted out of Medicare.The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that they contacted the office and confirmed the provider's status with 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 directlyby a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The dental services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay forthe bitewing x-rays (D0272), prophylaxis (D1110), and theperiodic oral evaluation (D0120) provided on October 21, 2019