Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sinus surgery to include bilateral sinus endoscopy with maxillary antrostomy, ethmoidectomy, sphenoidectomy, septoplasty, frontal sinus exploration with balloon sinuplasty, and submucus resection of the inferior turbinate.

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 services are not medically necessary.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found a nasal airway exam suggested septal deviation to the left. Fiber-optic upper airway laryngoscopy on the right demonstrated no abnormality. The left airway was difficult to evaluate due to the narrowness from the septal deviation. The nasopharynx, hypopharynx, and larynx were essentially normal with minimal reflux 2+ in the posterior larynx. A computed tomography (CT) scan revealed no findings of chronic or acute bilateral sinusitis. The records do nto support that the requested procedures are reasonable or medically necessary for the enrollee 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 sinus surgery to include bilateral sinus endoscopy with maxillary antrostomy, ethmoidectomy, sphenoidectomy, septoplasty, frontal sinus exploration with balloon sinuplasty, and submucus resection of the inferior turbinate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for binaural BTE, digital hearing aids (V5261) purchased August 19, 2020.

You asked the Plan to pay for the hearing aids. You say that you went to this provider because they were 1/3 of the price than going to an audiologist and had the best hearing exam you've ever had. You are quite pleased with your hearing aids. The Plan denied your request. The Plan says enrollee's must receive their hearing services from an in-network provider. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when services are received from an in-network provider. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for binaural BTE, digital hearing aids (V5261) purchased August 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 4 fillings provided on October 26, 2020.

You asked the Plan to pay for the dental services. You say that you were told that all 4 fillings would be paid by your insurance. You say that you received a notice for denied payment due to frequency limitations. You also say that you have not had any fillings prior to this date of service that were paid by the plan. The Plan denied your request. The Plan says 1 filling per calendar year is covered. The Plan says that the frequency limit has been exceeded. The Plan also says that the provider in this case is out of network.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 filling per calendar year has been exceeded. The record shows that the Plan paid for 1 filling that you received on this date of service. The Plan confirmed that the provider office did contact them regarding your benefits and were advised that the Plan provides coverage for 1 restoration per calendar year. Therefore, we decided that the Plan does not have to pay for 4 fillings provided on October 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.

You asked the Plan to pre-approve the requested LDCT scan. You say that the service is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for this service.

The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria. 

We reviewed the file and the Medicare rules. We find that the enrollee is not between the ages of 55-77 years. This means the member does not meet the criteria for LDCT. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services received from March 7, 2020 to October 8, 2020.

You asked the Plan to pay for the services. You say that this is covered in your contract. The Plan denied your request. The Plan says there is only coverage for in-network acupuncture.

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 rendering 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. Therefore, we decided that the Plan does not have to pay for acupuncture services received from March 7, 2020 to October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network chiropractor.

You asked the Plan to pre-approve these services. You say that you trust this provider. The Plan denied your request. The Plan says the services are available from network providers.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network chiropractor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial inpatient hospital care services (99221) provided on August 24, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the inpatient hospital care. You say that the provider should be paid for the services that was performed. Please do not hold the provider liable for authorization not being obtained. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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. Therefore, we decided that the Plan does not have to pay for the initial inpatient hospital care services (99221) provided on August 24, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implant services.

You asked the Plan to pre-approve dental implant services. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not covered under your supplemental benefit.

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 pre-approve dental implant services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical removal of an erupted tooth (D7210 x 2), the bone replacement grafts (D7953 x 2), the unspecified oral surgical procedures (D7999 x 2), and the unspecified preventive procedure (D1999) rendered by the out-of-network provider.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under your dental policy. Additionally, dental services rendered by an out-of-network provider 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, the bone replacement grafts, the unspecified oral surgical procedures, and the unspecified preventive procedure are not among those services covered under this benefit. Additionally, dental services rendered by an out of network provider are not covered. Therefore, we decided that the Plan does not have to pay for the surgical removal of an erupted tooth (D7210 x 2), the bone replacement grafts (D7953 x 2), the unspecified oral surgical procedures (D7999 x 2), and the unspecified preventive procedure (D1999) rendered by the out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provider is
not payable for these services.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the
procedure is covered for an assistant and the person who assists the surgery bears the designation of a
physician, PA, NP, or CNS.

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP,
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the follow-up with a specialist to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the follow-up with a specialist. You say that this is your last post-surgery follow up with a specialist and you would like to see them because they know everything about your eyes. The Plan denied your request. The Plan says the original date of the appointment was scheduled more than 12 months from the last visit with this provider. This does not qualify for continuity of care. The Plan says routine, annual, and follow-up visits or evaluation can be safely transitioned to an in-network provider.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the follow-up with a specialist to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee brace and suspension sleeve.

You asked the Plan to pay for the provided services. You say that a physical exam is not required during the pandemic. The Plan denied your request. The Plan says the claim processed correctly.

The Plan must follow Medicare rules. Medicare rules say that the enrollee's medical record must contain sufficient documentation of the medical condition to substantiate the necessity for the type and quantity of items ordered.

We find that the provided items are not supported in the medical record. The case file does not include previous medical records from the treating physician noting the enrollee's clinical course, prognosis, and extent of the enrollee's functional limitations. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the knee brace and suspension sleeve.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdomen x-ray.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 74018 is not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.

The provider submitted a claim for procedure codes 74018 and 74250. Code 74018 is a column II code with a modifier indicator of 1 when billed with column I code 74250. Code 74018 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the abdomen x-ray.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on March 30, 2020.

You asked the Plan to waive the copayment for the inpatient care. You say that you were approved as an inpatient, but you had the procedure done as an outpatient and did not stay overnight. The Plan denied your request. The Plan says medical records show that inpatient services were provided on the day in question. Inpatient care has a $325 copayment per admission.

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 $325 copayment per admission for inpatient hospital care. 

You have been asked to pay a $325 copayment for the inpatient care. These services were billed as inpatient care and medical records were provided to show that you had an inpatient status at the time the services were received. Please note that the inpatient care copayment also covers the other services (such as prescription drugs, therapy, surgical procedures, supplies and exams) that were provided to you. 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 inpatient hospital care provided on March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 16, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 October 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 speech therapy visits and 8 home health aide visits.

You asked the Plan to pre-approve the therapy and home health aide visits. You say that the enrollee needs speech therapy due to memory and recall deficits and word finding issues. He also needs home health aide services due to inability to perform activities of daily living on his own. The Plan denied your request. The Plan says the notes do not support progress to goals or improvement for speech therapy visits and do not indicate continued need with daily activities and there are natural supports in the home for home health visits.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 the therapy and home health aide visits. 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 reported to have dementia. The enrollee does not have functional speech or swallowing deficits. Ongoing home health and speech therapy visits are not medically necessary or reasonable to address the enrollee's dementia. The enrollee is able to ambulate within her home with minimal assistance. The services provided by the CNA appear to be custodial and are not shown to be part of a medical treatment plan. As such, ongoing home health aide services are not medically necessary or reasonable.

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 therapy and home health aide visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 speech therapy visits and 8 home health aide visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa.

You asked the Plan to pre-approve Vascepa. You say that this is necessary to reduce the enrollee's risk of heart attack and stroke. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

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 Vascepa.

Benefits for Vascepa may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for ultrasound. You say that you are appealing with the referring provider's order. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 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. Therefore, we decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a participating provider.

You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you do not agree with this. You say that you never had to pay for this before. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $350 copayment for outpatient surgery.

You have been asked to pay a $350 copayment for a diagnostic colonoscopy. The colonoscopy that was provided was diagnostic in nature; therefore, the correct copayment has been applied. A diagnostic colonoscopy falls within the outpatient surgery 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 diagnostic colonoscopy provided by a participating provider.