Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam and eye refraction provided on October 10, 2019 by an in-network provider.
You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 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). Review of the file show that you received an eye exam and eye refraction provided on October 10, 2019 by an in-network provider. You are responsible for a $25.00 co-payment for Medicare Covered Vision Services (Specialist Office). Eye refractions are not a covered benefit for Original Medicare. Your eye refraction charge has been forwarded for additional processing. 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 eye exam and eye refraction provided on October 10, 2019 by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on September 29, 2018.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the claim was not submitted within a year from the date of service.
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 services was not filed until November 6, 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 services provided to the enrollee on September 29, 2018.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee's needs are met in the current setting.
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 does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. All medically necessary care is being provided in the current acute care setting. 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: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the intraoral, periapical first film - 1 every 12 months (D0220). We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140), crown - porcelain/ceramic (D2740).
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan says that you do not have out-of-network benefits.
We decided that the Plan has to pay for the intraoral, periapical first film - 1 every 12 months (D0220).
The dental services benefit is not a Medicare benefit. It is a supplemental benefit offered by the plan that cover dental X-Rays (Choose one (1) per year): Intraoral, periapical first film - 1 every 12 months (ADA Code: D0220).
This means that the generic lock-in language in Chapter 3 is not sufficient. The limitation on a plan provider must be specifically listed for the hearing aid benefit. It is not, neither in the hearing aid section of the benefits chart (Chapter 4) nor in the exclusions list at the end of the benefit chart. Therefore, the plan as to provide coverage for intraoral, periapical first film - 1 every 12 months (ADA Code: D0220). We also decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and crown - porcelain/ceramic (D2740). The services are not listed in your EOC and are not covered. Therefore, we decided that the Plan does not have to pay for these services.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 21, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that 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 physician's services provided on August 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the catheters provided on September 16, 2019 and October
11, 2019 by an out of network provider.
You asked the Plan to pay for the catheters. You say that the catheters were medically necessary. The Plan
denied your request. The Plan says prior authorization was not requested.
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 at issue in this appeal. The Plan did not pre-approve the items at issue. We
found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does
not have to pay for the catheters provided on September 16, 2019 and October 11, 2019 by an out of network
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (RFA) of the spine (64636, 64635).
You asked the Plan to pre-approve a RFA of the spine. 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 follows Medicare rules. Medicare rules say that for each covered spinal region (cervical/thoracic or lumbar), no more than two (2) thermal radiofrequency (RF) sessions will be reimbursed in any rolling 12 month year. 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 RFA of the spine. Our reviewer says that the services are not medically necessary. Our physician reviewer found this request exceeds the limitation of no more than two RFA sessions in any rolling 12-month period per region. The requested procedure is therefore, deemed not medically reasonable or necessary. 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 RFA of the spine have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (RFA) of the spine (64636, 64635).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not a covered benefit.
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 Xiidra for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires prolonged hospitalization and close physician monitoring. The Plan denied your request. The Plan says the enrollee is medically stable and services can be provided in another setting.
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 physician reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. All medically necessary care is being provided in the current acute care setting. 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 health plan has approved ongoing care in the current acute care setting. 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laser hair removal.
You asked the Plan to pre-approve laser hair removal. You say that this is causing emotional distress. The Plan denied your request. The Plan says this is a cosmetic procedure.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. We looked at the file and Medicare rules. In this case, laser hair removal is considered a cosmetic procedure. The procedure is not required for the prompt repair of accidental injury or to improve the functioning of a malformed body member. Based on this information, we decided that Medicare rules for coverage of laser hair removal have not been met. Therefore, we decided that the Plan does not have to pre-approve laser hair removal.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat medial branch block (MBB) injections.
You asked the Plan to pre-approve these services. You say that you have pain in your left shoulder and neck for one year. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that repeat MBBs are covered when specific criteria are met. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have chronic neck and shoulder pain. You had prior diagnostic MBB injections that did not achieve documented 80 percent pain relief. Given that the first MBBs did not achieve a positive result of greater than 80 percent pain relief, the repeat MBBs are not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat medial branch block (MBB) injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral radiofrequency ablation (RF)A for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that RFA is covered when specific criteria are met. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. She had positive dual diagnostic facet blocks; however, the RFA that was performed provided only one week of pain relief. It is not medically reasonable to repeat a failed block. The enrollee does not meet the criteria for coverage and the repeat RFA is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral radiofrequency ablation (RF)A for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on May 13, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim approved for payment
based on medical necessity of these services. The Plan denied your request. The Plan says no prior
authorization was obtained for these services.
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 physician services provided on May 13, 2019 by
an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on March 28, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.
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 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 to the enrollee by an out-of-network provider on March 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two dental extractions, hospital facility fees and anesthesia.
You asked the Plan to pre-approve two dental extractions, hospital facility fees and anesthesia. You say that the services are medically necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 covers two dental extractions per calendar year. We looked at this the file and Medicare rules. Specifically, the benefit has been exhausted. Based on this information, we decided that the Plan's rules for coverage of two dental extractions, hospital facility fees and anesthesia have not been met. Therefore, we decided that the Plan does not have to pre-approve two dental extractions, hospital facility fees and anesthesia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI) for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a lumbar ESI is covered when specific criteria are met. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain status post lumbar fusion. She also has atrial fibrillation and is taking anti-coagulation medication. There was no documentation submitted addressing the stopping of the anti-coagulant; therefore, the requested ESI is not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based composite - four or more surfaces, posterior (D2394) and pin retention - per tooth, in addition to restoration (D2951) provided on June 27, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the services are not a covered benefit under the plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for resin-based composite - four or more surfaces, posterior (D2394) and pin retention - per tooth, in addition to restoration (D2951) provided on June 27, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transports provided on September 8, 2019 and September 17, 2019.
You asked the Plan to waive the copayment for the ambulance transports. You say that the transports were necessary. The claims should be reprocessed for additional payment. The Plan denied your request. The Plan says the copayments 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 $310 copayment for each Medicare-covered one-way trip via ground ambulance. The enrollee has been asked to pay a total of $604.08 for the ambulance transports.
Date of Service
Service
Allowed Amount
Standard Copayment
Member Liability
September 8, 2019
Ambulance Transport
$417.81
$310
$310
September 17, 2019
Ambulance Transport
$294.08
$310
$294.08
TOTAL:
$604.08
The ambulance transports fall within the "Ambulance services" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. 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 the ambulance transports provided on September 8, 2019 and September 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. The rules say that the patient must have a personal history of breast or ovarian cancer for BRCA testing to be covered. We looked at the file and Medicare rules. The enrollee does not have a personal history of cancer for which BRCA testing is approved. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA genetic testing for the enrollee.