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

 
We decided that the Plan does not have to waive the cost sharing for the magnetic resonance imaging (MRI) 
and the trigger finger injection procedure you had at an outpatient hospital facility on July 26, 2021. 
 
You asked the Plan to waive the cost sharing for the MRI and the injection procedure. You say that you used 
plan doctors and you paid you $125 copayment, so you don't know why you are getting this bill. The Plan 
denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that for the 
injection procedure, the allowed amount ($234.56) is less than your copayment obligation, so you are 
responsible for the full allowed amount for that service. 
 
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 $125 
copayment for diagnostic radiology and a $275 copayment for outpatient hospital services.  Records show that you had two separate services at the outpatient hospital: you had an MRI, and you had an 
injection procedure in a treatment room. You have been asked to pay a $125 copayment for the MRI and a 
$275 copayment for the injection procedure. The MRI and falls within the diagnostic radiology benefit 
category. You received the injection procedure in an outpatient hospital facility. 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 sharing for the magnetic resonance imaging (MRI) and the trigger finger injection procedure 
you had at an outpatient hospital facility on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99336) provided on June 17, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says there were network providers available. 
 
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 physician services (99336) provided on June 17, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home sleep study test provided on January 19, 2021. 
 
You asked the Plan to pay for a home sleep study test. You say that this claim should be processed per the 
contracted fee schedule. The Plan denied your request. The Plan says a home sleep study unattended, is not a 
Medicare benefit for the diagnoses listed on the claim and is done for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that ICD-10-CM Codes that DO NOT Support 
Medical Necessity. Group 1. All those not listed under the ?ICD-10 Codes that Support Medical Necessity?. 
 
We looked at the file and Medicare rules. The rules do not include snoring as a diagnosis that is covered for a 
home sleep study. Based on this information, we decided that Medicare rules for coverage of a home sleep 
study test have not been met. Therefore, we decided that the Plan does not have to pay for a home sleep study 
test provided on January 19, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for physical therapy services provided from August 10, 2020, through September 18, 2020.
You asked the Plan to pay for physical therapy services. You say that you were told that the services would be covered. The Plan denied your request. The Plan says that services rendered by a non-contracted provider require authorization and there is not one on file.
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. You were referred for physical therapy services by a contract provider. The file does not show that the Plan provided notice that physical therapy services would not be covered prior to being rendered. Under Medicare rules, this means physical therapy services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for physical therapy services provided from August 10, 2020, through September 18, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services received 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says testing that is ordered or performed solely for purposes of pandemic control or re-opening the 
economy, and not based on a determination by an attending provider that the test is medically appropriate for 
the diagnosis and treatment of an individual member, is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The test was not ordered by your treating physician, so it cannot be covered. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for testing services received
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling and root planning, and anesthesia (D4341, D9215) 
provided May 4, 2021. 
 
 
You asked the Plan to pay for the scaling and root planning, and anesthesia. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the services at issue are not covered under 
your dental 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 pay for scaling 
and root planning, and anesthesia (D4341, D9215) provided May 4, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a PSA test provided on June 9, 2021. 
 
You asked the Plan to pay for a PSA test. The Plan denied your request. The Plan says denial of payment for 
the PSA test you received on June 9, 2021 is correct. The service is covered once every 12 months and the Plan 
previously issued payment for the service billed for January 18, 2021, which is within the 12-month limitation. 
 
The Plan must follow Medicare rules. Medicare rules say that screening prostate specific antigen tests are 
covered at a frequency of once every 12 months for men who have attained age 50 (at least 11 months have 
passed following the month in which the last Medicare-covered screening prostate specific antigen test was 
performed). 
 
We looked at the file, the Plan?s rules and the Medicare rules. Medicare rules say that screening prostate 
specific antigen tests are covered at a frequency of once every 12 months for men who have attained age 50.  The file shows that the Plan previously issued payment for a PSA test provided on January 18, 2021, which is 
within the 12-month limitation. Based on this information, we decided that Plan?s rules and the Medicare rules 
for coverage of a PSA test have not been met. Therefore, we decided that the Plan does not have to pay for a 
PSA test provided on June 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care associated with an elective left shoulder joint replacement surgery (23472).
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the inpatient admission covered. The Plan denied your request. The Plan says the surgery is approved but the associated inpatient admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The review has determined that the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care associated with an elective left shoulder joint replacement surgery (23472).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient hospital stay provided on October 4, 2020, to October 9, 2020.
You asked the Plan to pay for an inpatient hospital stay. You say that the enrollee and his wife wanted the member to be evaluated. The Plan denied your request. The Plan says the originating hospital was able to manage the needs of this enrollee.
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 pay for inpatient hospital care. Our reviewer says that there was no specific clinical rationale for this transfer. Our physician reviewer found a transfer to a different facility was not medically necessary in this case. Our doctor found that the services could have been safely rendered at the originating hospital.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient hospital stay provided on October 4, 2020, to October 9, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reimburse you for any amount in excess of your contracted cost share for the
durable medical equipment. We decided that the Plan does not have to reimburse you for your 20%
coinsurance for durable medical equipment.
You asked the Plan to reimburse you for any amount in excess of your contracted cost share for the durable
medical equipment. You say that you would like reconsideration because you have been overpaying for the
durable medical equipment. The Plan says that this claim has processed per your 2019 benefits.
We decided that the Plan has to reimburse you for any amount in excess of your contracted coinsurance.
The Plan follows Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in clear,
accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance).
The file shows that you have paid for these services up front. The documentation submitted indicates that you
have paid more than your contracted coinsurance amount. It is the Plan's obligation to ensure that you only pay
for your contractual cost-share obligation, and they can do that by either paying you directly for the difference,
or by directing the provider to do so. You are only responsible for your cost share to network providers.
Therefore, we decided that the Plan has to reimburse you for any amount in excess of your contracted
coinsurance.
We also decided that the Plan does not have to reimburse you for your 20% coinsurance for durable
medical equipment.
The Plan follows Medicare rules. Medicare rules say that a copayment is a fixed amount charged to an enrollee
on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health
care service that can be charged to an enrollee on a per-service basis. The Health Plan contract says that you are
responsible for a 20% coinsurance for durable medical equipment.
We looked at your request and the rules. Based on this information we determined that the coinsurance that has
been assessed is correct. You have been asked to pay a 20% coinsurance for durable medical equipment.
Therefore, we decided that the Plan does not have to reimburse you for your 20% coinsurance for durable
medical equipment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on June 14, 2021.
You asked the Plan to pay an additional amount for eyeglasses. You say that you were told by the Provider that the $150 allowance was available to you as you had not received a new prescription or eyeglasses in seven years. The Plan denied your request. The Plan says the total cost for the eyeglasses was $364. The benefit of $150 allowance was applied to the purchase, leaving you with a member responsibility of
$214, which was paid at the time of purchase. The benefit was applied correctly.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan benefit allowance of $150 was applied to
the purchase of the eyewear. Therefore, we decided that the Plan does not have to pay an additional amount for
eyeglasses provided on June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implants (D6010).
You asked the Plan to pre-approve the implants. You say that the service is medically necessary. The Plan denied your request. The Plan says implants are a benefit to replace a single missing tooth, with no other missing teeth in the arch. The implants are denied as there are more than one missing tooth in the arch. Additionally, this patient has no history of replacing the teeth with a removable denture, and no medical history which would prevent the use of full dentures. Furthermore, the replacement of each individual tooth with 14 implants in the upper arch alone as per this treatment plan would be excessive.
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 implants 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 implants. Our reviewer says that the service is not medically necessary. Our physician reviewer found the bone integrity being poor due to severe periodontal disease preventing the use of multiple implants as suggested as well as the common standard of replacing full arch tooth loss with an implant supported prosthesis if necessary would make the proposed treatment plan not medically necessary; full dentures should be considered in this scenario. 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 implants have not been met. Therefore, we decided that the Plan does not have to pre-approve the implants (D6010).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Hepatitis vaccine provided on May 17, 2021.
You asked the Plan to pay for this vaccine. You say that this vaccine should be covered by the Plan. The Plan denied your request. The Plan says the Hepatitis B vaccine (90636), is listed if you are at high or intermediate risk of getting Hepatitis B, however, no medical records were submitted by your physician. The Hepatitis A vaccine, (90636), is not listed as covered and is therefore not covered by the Part B plan. The Plan also states that some vaccines are covered under the Part D prescription drug benefit. A claim for reimbursement may also be submitted to your Medicare Part D contract. In addition, you are a Dual Eligible beneficiary. Services that are not covered under the plan may be eligible for coverage under your State Medicaid benefits.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for individual outpatient treatment by a
licensed clinical mental health counselor.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says this provider is not eligible to be billable by Medicare.
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are
enrolled in the Medicare program.
A Licensed Clinical Mental Health Counselor is not eligible to bill Medicare. We found no exception that
would require the plan to pre-approve these items/services. Based on this information, we decided that
Medicare rules for coverage of the referral have not been met. Therefore, we decided that the Plan does not
have to pre-approve a referral for individual outpatient treatment by a licensed clinical mental health counselor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on November 3, 2020 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for lab tests. You say that there was not an in-network laboratory or any alternative 
who could offer the appropriate service needed. The Plan denied your request. The Plan says the denial of 
payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering 
provider is also out-of-network with the Plan. 
 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 laboratory testing provided on November 3, 2020 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the external insulin pump (E0784).
You asked the Plan to pre-approve the insulin pump. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee has previously received the same supplies within the 5-year RUL.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition.
We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same durable medical equipment in December 2020. This is still within the 5-year RUL and the documentation submitted does not show that the insulin pump is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the DME at issue. There is no documentation that a repair or replacement for the duration of the current rental was requested. Based on this information, we decided that Medicare rules for coverage of the insulin pump have not been met. Therefore, we decided that the Plan does not have to pre-approve the external insulin pump (E0784).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency transportation provided on April 13, 2021 and April 23, 2021.
You asked the Plan to pay for the non-emergency transportation. You say that the benefits at a glance (BAG) does not say anything about non-emergency transportation needing to be scheduled 3 days in advanced or that you have to work through the Plan's transportation coordinator. The Plan denied your request. The Plan says your contract states that wheelchair van, stretcher van and ambulette transportation are not covered. You have coverage for up to 6 one-way trips that is a planned service through the Plan's transportation coordinator and must be pre-scheduled to apply the transportation benefit according to your contract.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation up to 6 one-way trips to a Plan network approved location. The Plan coordinates rides that are appropriate for your health needs. Schedule rides at least 3 days in advance. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pay for non-emergency transportation provided on April 13, 2021 and April 23, 2021.