Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for lab work provided by the medical laboratory.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says that you must use in-network providers.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.

The enrollee was referred for lab work by a contract provider. The file does not show that the plan provided notice that lab work would not be covered. Under Medicare rules, this means lab work is considered approved by the plan. Therefore, we decided that the Plan has to pay for lab work provided by the medical laboratory.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator provided by an OON provider.

You asked the Plan to pay for the automatic external defibrillator. You say that you would like this claim
reprocessed. The Plan denied your request. The Plan says the cost share has processed correctly in this case.

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 durable medical equipment.

You have been asked to pay a total cost share of $4251.08 for the automatic external defibrillator. The
automatic external defibrillator falls within the durable medical equipment benefit category. The claim, processed
with a 20% coinsurance. However, date of service you had exhausted your $5,000 benefit for point of service 
OON claims. The Plan covered the remaining benefit and charged you the difference. 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 pay for the automatic external defibrillator provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a part B injection provided to the enrollee.

You asked the Plan to pay for the injection. You say that the out-of-pocket maximum was already met.
The Plan denied your request. The Plan says the coinsurance was applied correctly according to the benefits and the services rendered.

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 drugs.

You have been asked to pay 20% coinsurance for the injection. the injection falls within the Medicare Part B drugs benefit category. The out-of-pocket maximum had not been met at the time of 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 pay for a part B injection provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implants (D6010) for teeth # 3 and 13.

You asked the Plan to pay for the dental services. You say that you did not know that implants were not covered for posterior teeth. You also say that you would like for the implants to be covered. The Plan denied your request. The Plan says implants are only covered for anterior (front) teeth. The Plan says that teeth # 3 and 13 are posterior (back) teeth. The Plan also says that implants for posterior teeth 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.

Though the Plan offers a dental benefit in excess of Medicare coverage and implants are a covered service, implants for posterior teeth are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the implants (D6010) for teeth # 3 and 13.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan.

You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the charges because you were informed the enrollee would not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $325 copayment for diagnostic radiology services.

The enrollee has been asked to pay a $325 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies 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 a CT scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).

You asked the Plan to pay for the lumbar-sacral orthosis. You say that this service was medically necessary for the enrollee. The Plan denied your request. The Plan says there is no evidence the prescribing physician ever saw the member.

The Plan follows Medicare rules. Medicare rules say that for a spinal orthosis to be covered the Medicare criteria as listed in the Rules section must be 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 pay for the lumbar-sacral orthosis. Our reviewer says that the lumbar-sacral orthosis was not medically necessary and reasonable. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back.

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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit.

You asked the Plan to waive the copayment for the emergency room visit. You say that you are appealing this amount. You say your income for monthly retirement is $180. The Plan denied your request. The Plan says you have been asked to pay 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 $50 copayment for emergency care. 

You have been asked to pay a $50 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" 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 emergency room visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontics (D6251) for teeth #3 and 30, and retainer
crowns (D6751) for teeth #2, 4, 5, 29, and 31.

You asked the Plan to pre-approve the dental services. You say that when you signed up for the plan you were
advised that bridgework was covered. You say that your request for bridgework has been denied. You say that
now you are being told that there are conditions to coverage for the bridgework. You also say that the appeal
process is very cumbersome. The Plan denied your request. The Plan says the requested fixed bridges are
beyond the scope of the policy.

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 the dental
services when the services are medically necessary and reasonable.

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 dental services. Our reviewer says
that the fixed bridges do not meet the criteria for coverage. Our physician reviewer found fixed bridges are
considered for coverage in the anterior region only unless there is documentation that removable prostheses
cannot be used to replace missing posterior teeth due to medical or psychological issues. The reviewer found
that there is no documentation to support the need for fixed bridges in this case. Therefore, the reviewer found
that the fixed bridges do not meet the criteria for coverage.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does
not have to pre-approve pontics (D6251) for teeth #3 and 30, and retainer crowns (D6751) for teeth #2, 4, 5, 29,
and 31.

Your complaint about being misled by a plan representative is not a valid appeal for medical coverage. This
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.

You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care continues to be
medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 the continuation of SNF care. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have
documented skilled nursing needs. In addition, you do not have documented skilled therapy needs. Daily
skilled services are not required to establish a maintenance program or to prevent deterioration of your
condition. Your care needs, as a practical matter, can be provided at a lower level of 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 the continuation of SNF care have not been met. Therefore, we decided that the
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the vision exam.

You asked the Plan to adjust the services. The Plan denied your request. The Plan says you are responsible for the 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 $45 copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye.

The records show that you had an eye exam. You have been asked to pay a $45 copayment for the exam. The exam falls within the vision care 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 adjust the copayment for the vision exam.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751) for tooth # 4.

You asked the Plan to pre-approve the dental service. You say that the crown is medically necessary. The Plan
denied your request. The Plan says there is enough tooth left to repair with a filling. The Plan also says that the
crown is not medically necessary.

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 the dental
service when the services are medically necessary and reasonable.

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 dental service. Our reviewer says
that the crown is not medically necessary. Our physician reviewer found that tooth # 4 presents with an existing
2 surface restoration and no obvious decay. The reviewer found that the Plan's criteria for coverage states that
consideration for crown restorations are made where there are 3 or more involved surfaces of a premolar tooth
as well as a cusp. The reviewer found that in this instance, there are only 2 surfaces involved with no new
caries seen. Given the lack of tooth damage present on tooth # 4, the reviewer found that there would be no
medical necessity for a crown on tooth # 4.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does
not have to pre-approve a crown (D2751) for tooth # 4.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an injection procedure for sacroiliac joint.

You asked the Plan to pre-approve an injection procedure for sacroiliac joint, anesthetic/steroid, with image
guidance (fluoroscopy or CT) including arthrography when performed (27096). You say that you are in pain
and cannot sleep during the night. The Plan denied your request. The Plan says you have not tried chiropractic
or physical therapy services for 6 weeks and there was no physical exam.

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 injection procedure for sacroiliac joint,
anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (27096).
Our reviewer says that the requested services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the lack of a physical exam and a lack of recent conservative therapy does
not meet standard to approve interventional therapy. The request is 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 injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance
(fluoroscopy or CT) including arthrography when performed (27096) have not been met. Therefore, we
decided that the Plan does not have to pre-approve an injection procedure for sacroiliac joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L2397, L1833).

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the services provided were
medically necessary. The Plan denied your request. The Plan says there is no evidence that the prescribing
physician ever saw the member.

The Plan follows Medicare rules. Medicare rules say that for the knee orthosis to be covered, knee instability
must be documented by examination of the beneficiary and objective description of joint laxity.

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 knee orthosis and suspension sleeve. Our
reviewer says that the services are not medically necessary and reasonable. Our physician reviewer found there
is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective
documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the
base item is not covered.

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 knee orthosis and suspension sleeve have not been met. Therefore, we
decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L2397, L1833).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you 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 a $225 copayment for days 1-7 for inpatient hospital care.

You had an inpatient hospital stay. Therefore, you are responsible to pay a $225 copayment for days 1-7 (February 5, 2020, to February 11, 2020). $225 (copayment) x 7 (inpatient days) = $1,575.

You have been asked to pay the total copayment amount of $1,575 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a raised toilet seat (E0244).

You asked the Plan to pay for a raised toilet seat. You say that you were unaware that the item at issue had been ordered for you. 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 raised toilet seats are not covered because they are not primarily medical in nature.

While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a raised toilet seat (E0244).

Your complaint about receiving a raised toilet seat you had not ordered is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc One.

You asked the Plan to pre-approve Synvisc One. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet step therapy criteria.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Synvisc One. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has pain related to osteoarthritis of the left knee, diagnosis confirmed with imaging studies. The documentation does not support that the enrollee has tried and failed Euflexxa, Supartz FX, Durolane, or Gelsyn-3. The documentation does not support that the plan's required drugs would likely be less effective and/or likely have adverse effects 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 Synvisc One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc One.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endovascular revascularization procedure (37224, 37226, 37225 and 27227).

You asked the Plan to pre-approve an endovascular revascularization procedure. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee meets criteria for the requested procedure; however, the enrollee is enrolled in hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee is under the Medicare hospice benefit. Original Medicare pays claims for services related to the terminal illness and Medicare-covered non-hospice services. Therefore, we decided that the Plan does not have to pre-approve an endovascular revascularization procedure (37224, 37226, 37225 and 27227).