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

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and extraction (D7140) provided on January 5, 2021, by an OON provider.

You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and extraction. You say that you contacted the Plan for a list of in-network providers in November. You also say that the dental office contacted the Plan to verify benefits and eligibility prior to these services being rendered. The Plan denied your request. The Plan says your plan does not cover services from a provider who is not in-network. The Plan also says that no attempts were made to contact the Plan prior to these services being rendered.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and extraction (D7140) provided on January 5, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431) provided on April 27, 2021.

You asked the Plan to pay for the adjunctive pre-diagnostic test. You say that your dentist contacted the Plan and confirmed that this service would be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan says that your provider was given no misinformation during their call with the Plan, and the provider advised that they are aware this service is not normally covered so they would not have told you it was 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431) provided on April 27, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detections by nucleic acid (U0003 and U0005) provided on January 19, 2021.

You asked the Plan to pay for the infectious agent detections. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the infectious agent detections by nucleic acid (U0003 and U0005) provided on January 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code 99998.

You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are medically necessary due to diabetes. The Plan denied your request. The Plan says there is no qualifying wound and the requested socks are not primarily medical in nature.

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code 99998 are covered only when they are used to treat an open venous stasis ulcer. 

Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. 

The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 99998.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for practitioner services provided on July 4, 2020.

You asked the Plan to pay for practitioner services. You say that the patient was admitted to hospice on July 7, 2020, after the services were performed. You say that the Plan is responsible for payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for practitioner services provided on July 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit and eligible clinician attestation provided on March 16, 2021 by an OON provider.

You asked the Plan to pay for the domiciliary or rest home visit and eligible clinician attestation. You say that your providers have been flagged as OON inaccurately. The Plan denied your request. The Plan says prior 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 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 domiciliary or rest home visit and eligible clinician attestation provided on March 16, 2021 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient rehabilitation stay provided from November 20, 2020, to December 8, 2020.

You asked the Plan to waive the copayment for an inpatient rehabilitation stay. You say that you disagree with being charged a second copayment for the stay. You already paid a copayment and feel that the stay should be considered continuous and not separate. 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 1-6 for inpatient hospital care. For inpatient hospital care, the cost-sharing described above applies to each time you are admitted to the hospital. A transfer to a separate facility type such as inpatient rehabilitation is considered a new admission. 

You had an inpatient rehabilitation stay from November 20, 2020, to December 8, 2020. This is considered a new admission. Therefore, you are responsible to pay a $225 copayment for days 1-6 (November 20, 2020, to November 25, 2020). $225 (copayment) x 6 (inpatient days) = $1,350. 

You have been asked to pay the total copayment amount of $1,350 for an inpatient rehabilitation stay. An inpatient rehabilitation 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 rehabilitation stay provided from November 20, 2020, to December 8, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional physical therapy visits.

You asked the Plan to pre-approve 4 physical therapy visits. You say that you need to continue with physical therapy services. The Plan denied your request. The Plan says additional visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 4 physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the unique skills of a physical therapist are not required to continue to treat your chronic pain. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional physical therapy visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on February 3, 2021.

You asked the Plan to waive the copayment for an EGD. You say that you have a history of cancer and were told that you would not owe a copayment. 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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 

You received an EGD on February 3, 2021. An EGD is not included in colorectal cancer screenings and are subject to separate cost-sharing charges. Therefore, you are responsible to pay the $250 copayment. 

You have been asked to pay a $250 copayment for an EGD. An EGD falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 EGD provided on February 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on April 13, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory work. You say that you did not know the provider was out-of-network. The Plan denied your request. The Plan says no prior authorization was 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. The record shows your PCP is part of a medical group which means you must use a laboratory provider that is contracted with the medical group. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on April 13, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric scooter.

You asked the Plan to pre-approve an electric scooter. You say that you have a hard time getting around and you cannot drive so you need an electric scooter to get to the pharmacy and gym. The Plan denied your request. The Plan says the notes show you only plan to use the PMD outside your home and that you are able to walk with a cane or walker inside your home. 

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.

The file does not show that you do not have a mobility deficit that impairs your participation in MRADLs and shows that your condition can be improved by a walker and a cane. This means that Medicare rules for coverage of a PMD have not been met. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers PMDs for use only outside the home. Therefore, we decided that the Plan does not have to pre-approve an electric scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary interim partial denture (D5820) provided on March 8, 2021.

You asked the Plan to pay for the maxillary interim partial denture. You say that the provider felt that the use of a simple partial denture was the most expedient way to handle the temporary problem. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that you did not contact the customer service department prior to receiving this service to verify your benefits or check dental coverage.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the maxillary interim partial denture (D5820) provided on March 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided form January 18, 2021, to January 20, 2021.

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 $295 copayment for days 1-5 for inpatient hospital care.

You had an inpatient hospital stay from January 18, 2021, to January 20, 2021. Therefore, you are responsible to pay a $295 (copayment) for days 1-2 (January 18, 2021, to January 19, 2021). The total amount you owe is: $295 (copayment) x 2 (inpatient days) = $590. 

You have been asked to pay the total copayment amount of $590 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 provided form January 18, 2021, to January 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit (Q5105).

You asked the Plan to pre-approve Retacrit. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says you do not have an adequate iron store. The Plan also says that the requested injection is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Retacrit. Our reviewer says that the request for Retacrit is not medically necessary. Our physician reviewer found the provided documentation indicates that the enrollee's iron levels are low. The reviewer found that the enrollee's transferrin saturation was 8%. Therefore, the reviewer found that the requested drug 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 Retacrit have not been met.

Specifically, the file does not indicate that the enrollee's transferrin saturation is greater than 20%. Therefore, we decided that the Plan does not have to pre-approve Retacrit (Q5105).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 7, 2021 by an OON provider.

You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that there are no in-network dentists within 60 miles of you. The Plan denied your request. The Plan says your responsibility was applied correctly per your plan benefits. The Plan also says that there are in-network providers in your area.

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, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 7, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy services.

You asked the Plan to pre-approve medical nutrition therapy services. You say that your oncologist says nutrition is very valuable for treatment. The Plan denied your request. The Plan says the record shows you do not have diabetes or a renal disease.

The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. 

Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a bone marrow biopsy provided on December 31, 2020.

You asked the Plan to waive the copayment for a bone marrow biopsy. 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 $275 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 

You received a bone marrow biopsy at an outpatient hospital facility on December 31, 2020. A bone marrow biopsy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $275 copayment.

You have been asked to pay a $275 copayment for a bone marrow biopsy. A bone marrow biopsy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a bone marrow biopsy provided on December 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screen (81404, 81407, 81408) provided on March 15, 2021.

You asked the Plan to pay for a hereditary cardiovascular screen. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. 

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular screen have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular screen (81404, 81407, 81408) provided on March 15, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for an office visit provided on February 15, 2021.

You asked the Plan to waive the copayment for an office visit. You say that this was your annual wellness visit and you should not owe a copayment. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide medical records. Without medical records we cannot determine whether or not you received services beyond an annual wellness exam. Therefore, we decided that the Plan has to waive the copayment for an office visit provided on February 15, 2021.

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.