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

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on April 2,
2021.
You asked the Plan to pay for the dental service. You say that a plan representative advised you should use
medical coding instead of dental for your dental issues related to your radiation treatments. You say that no one
could give you the codes. You also say that you feel these services should be covered. The Plan denied your
request. The Plan says limited oral evaluation is not listed as a covered dental service. The Plan also says that
your dental claims were forward to medical for review.
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 limited oral evaluation is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
limited oral evaluation (D0140) provided on April 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic equipment provided on March 17, 2020 to
January 2, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says supplies must be
obtained from a network vendor.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided 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 diabetic equipment provided on March 17, 2020 to January 2, 2021 by an out of
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gingival irrigation (D4921 x4), periodontal maintenance (D4910), and topical application of fluoride (D1206) provided on March 5, 2021.

You asked the Plan to pay for gingival irrigation, periodontal maintenance, and topical application of fluoride. You say that the services were necessary for your remaining teeth. The Plan denied your request. The Plan says the services at issue are not covered benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

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 gingival irrigation (D4921 x4), periodontal maintenance (D4910), and topical application of fluoride (D1206) provided on March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for compression sleeves (E0673) for a pneumatic compression device.

You asked the Plan to pay for a pneumatic compression device. You say that you are appealing this denial. The Plan denied your request. The Plan says this item is not covered by Medicare.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules state that if a base PCD is not covered, related accessories are not eligible for reimbursement.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD sleeves have not been met. Specifically, the base PCD is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Because the base PCD is not covered, these related accessories are not covered. Therefore, we decided that the Plan does not have to pay for compression sleeves (E0673) for a pneumatic compression device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a behavioral health consultation to be provided by an out of network provider.
You asked the Plan to pre-approve a behavioral health consultation with an out of network provider. You say that the therapy you need is not available in network. The Plan denied your request. The Plan says your plan covers the treatment of your mental health condition and providers are available in network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a behavioral health consultation to be provided by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the general health panel provided on January 22, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the service is
excluded by Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 80050 is a general health panel. We find that CPT code
80050 is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the general
health panel provided on January 22, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from March 6, 2021, to March 9, 2021.

You asked the Plan to waive the copayment for the emergency room visit. You say that you took your mother to the hospital in good faith, not being aware of the Plan's requirements for treatment. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 copayment for emergency services at an in-network emergency room.

The enrollee has been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" 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 emergency room visit provided from March 6, 2021, to March 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Clarifix procedure.
You asked the Plan to pre-approve the Clarifix procedure. You say that this is medically necessary. The Plan denied your request. The Plan says the requested procedure is not medically necessary as the enrollee's condition is well-managed.
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 the Clarifix procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 78-year-old man with a diagnosis of chronic rhinitis. The office notes document that moderate-severe vasomotor rhinitis symptoms, with associated itchy eyes, nasal obstruction, clear rhinorrhea, and sneezing. In this case, the requested procedure is not medically necessary as the enrollee's symptoms are noted to be well-controlled on the current medical regimen. 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 Clarifix procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Clarifix procedure.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the magnetic resonance imaging (MRI) provided on September 25, 2020.

You asked the Plan to waive the cost shares for the services provided. You say that the service was fully covered in the past. The Plan denied your request. The Plan says the claim processed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for diagnostic radiology services. 

The file shows that you received a breast MRI on the date of service at issue. You have been asked to pay a 20% coinsurance for the facility fee, and a 20% coinsurance for the physician's fee. The services fall within the outpatient diagnostic tests 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 cost shares for the magnetic resonance imaging (MRI) provided on September 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the laryngoscopy and the MRI provided on January 12, 2021 and February 25, 2021.
You asked the Plan to waive the copayments for the laryngoscopy and the MRI. You say that you should not be responsible for the copayments. 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 $270 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges and a $110 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in an in-network physician's office or at an in-network free-standing facility (such as a radiology center or medical clinic). You have been asked to pay a $270 copayment for the laryngoscopy and a $107.02 copayment, which is less than the standard amount, for the MRI. The laryngoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The MRI falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the laryngoscopy and the MRI provided on January 12, 2021 and February 25, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the monitoring services provided on December 22, 2020.

You asked the Plan to pay for the monitoring services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the provider is not enrolled in the Medicare program.

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. In this case, the Plan has provided no documentation showing that the provider is not enrolled in the Medicare program. The Plan has not provided enough information to verify that the provider is not enrolled in the Medicare program. Therefore, we decided that the Plan has to pay for the monitoring services provided on December 22, 2020.

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 pre-approve the non-sterile gloves (A4927) and skin sealant.
You asked the Plan to pre-approve incontinence supplies. You say that you are a quadriplegia and need the gloves and sealant protection to assist with using the bathroom. The Plan denied your request. The Plan says coverage for gloves is allowed when a member is performing dialysis in the home and this Member is not. Additionally, this request for a skin sealant cannot be approved as the skin is intact per the documentation and it therefore is not medically reasonable and necessary.
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-approve the non-sterile gloves (A4927) and skin sealant.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for physician services provided by an out-of-network provider on July 13, 2020.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says that prior authorization was not obtained by the member's primary care physician.

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 has failed to include a 2020 Evidence of Coverage; therefore, a decision cannot be rendered. Therefore, we decided that the Plan has to pay for physician services provided by an out-of-network provider on July 13, 2020.

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 pre-approve occipital nerve block injections.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there are not enough studies to show it works for headaches.

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 the requested services. Our physician reviewer found that you have chronic migraine headaches and degenerative disc disease in your cervical spine. You have had a cervical epidural steroid injection. This request is for bilateral occipital ultrasound guided nerve blocks. This is considered an experimental/investigational procedure for the treatment of migraine headaches. There are other evidence-based therapies available. Therefore, the request is 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve occipital nerve block injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670).

You asked the Plan to pre-approve an automatic blood pressure monitor. You say that the item is medically necessary. The Plan denied your request. The Plan says the member is not on home dialysis; thus the item is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. 

The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF is necessary to promote the quickest possible recovery. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you do require
physical and occupational therapy, there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. There is not a reasonable expectation
that you will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program
provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit and does not have to waive the coinsurance for Medicare Part B drugs provided from May 13, 2020, to May 26, 2020.

You asked the Plan to waive the copayment for a specialist visit and to waive the coinsurance for Medicare Part B drugs. You say that you kept receiving statements that you did not owe anything. You also disagree with the fact that the provider was billed as out-of-network and that you are responsible for 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 $40 copayment for specialist visits. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B drugs. 

You had a specialist visit on May 13, 2020. Therefore, you are responsible to pay the $40 copayment. 

You received a Medicare Part B drug on May 20, 2020. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $261.30 and 20% of that is $52.26. 

You received a Medicare Part B drug on May 20, 2020. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $6,790.80 and 20% of that is $1,358.16. 

You received a Medicare Part B drug on May 26, 2020. Therefore, you are responsible to pay $257.28, which is less than the 20% coinsurance amount. 

The total amount you owe is: $1,707.70. 

You have been asked to pay the total amount of $1,707.70 for a specialist visit and Medicare Part B drugs. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. Medicare Part B drugs fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit and does not have to waive the coinsurance for Medicare Part B drugs provided from May 13, 2020, to May 26, 2020.