Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August
9, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not owe
anything. The Plan denied your request. The Plan says you have been charged 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 $30
copayment for each specialist visit.
You have been asked to pay a $30 copayment for the specialist office visit. Specialist office visits fall within
the Physician/Practitioner Services, Including Doctor's Office Visits 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 office visit provided on August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing services provided on May 1, 2020.
You asked the Plan to pay for the hearing services. The Plan denied your request. The Plan says we need copy
of the itemized bill.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the hearing services have not been met. Therefore, we decided that the Plan does not have to pay
for the hearing services provided on May 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the portable oxygen concentrator (E1392), provided on April 16, 2021.

You asked the Plan to waive the cost share for the portable oxygen concentrator. You say that the item is medically necessary and should be covered. The Plan denied your request. The Plan says the cost share was applied 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 25% out of network coinsurance for durable medical equipment (DME) and related supplies. 

You have been asked to pay a 25% out of network coinsurance for the portable oxygen concentrator. This item falls within the durable medical equipment (DME) and related supplies benefit category. Because you received this item out-of-network , you must pay your $750 deductible before the coinsurance applies. 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 share for the portable oxygen concentrator (E1392), provided on April 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on May 18, 2021.
You asked the Plan to pay for the hearing aids. You say that you paid $3,067.45 but the hearing aids should have only cost $699. You say that part of the bill should have been reimbursed. The Plan denied your request. The Plan says you must use an in-network provider to purchase hearing aids.
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 they are received from a Plan provider. We looked at the case 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. Specifically, the hearing aids were not purchased from the Plan's hearing aid vendor. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on May 18, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pay for the computed tomographic angiography, abdomen and pelvis (74174) provided May 13, 2021.  

You asked the Plan to pay for the imaging services. You say that the enrollee was not inpatient. Your provider has provided medically necessary services to the enrollee for their well-being and should be reimbursed for the services provided. The Plan denied your request. The Plan says that services are not paid separately when the patient is an inpatient.  

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. There was no information provided from the Plan that shows that this enrollee was inpatient in either a hospital or in a skilled nursing facility. The Plan did not provide any information to support their reason to continue to deny. Therefore, we decided that the Plan has to pay for the computed tomographic angiography, abdomen and pelvis (74174) provided May 13, 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.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Arikayce suspension.  

You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.  

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 Arikayce suspension.   

Benefits for self-administered drug 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  

You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.   

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  

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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 

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 pay for the self-administered drugs provided from August 22, 2021, to August 24, 2021.  

You asked the Plan to pay for the self-administered drugs. You say that you do not agree with the Plan's decision to deny the self-administered medications for these dates of service. The Plan denied your request. The Plan says self-administered drugs are not covered under Part B of Original Medicare and they are not covered under the medical benefits for members of this 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 pay for the self-administered drugs provided from August 22, 2021, to August 24, 2021.   

Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the refraction provided on June 23, 2021.  You asked the Plan to pay for the refraction. You say that you had no way of knowing you had to use a certain provider. You say that since the provider is in-network you should be reimbursed. The Plan denied your request. The Plan says the claim processed correctly.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers this service when it is received with a routine eye exam.  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 refraction have not been met. Specifically, the refraction was not performed with a routine eye exam. Therefore, we decided that the Plan does not have to pay for the refraction provided on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pre-approve 4 additional acupuncture visits.  You asked the Plan to pre-approve 4 additional acupuncture visits. You say that you have severe arthritic pain. You say that the Plan approved the first 4 visits but denied another 4. You say that you felt improvement with the first 4 treatments but need to continue. The Plan denied your request. The Plan says that the medical necessity requirements have not been met for treatment of the enrollee's condition or symptoms. The Plan says that the enrollee's pain level, ability to move, muscle strength, and ability to do daily tasks has not improved very much with care.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. The Plan contract says that acupuncture is covered for up to 25 visits per calendar year when being used to relieve pain or for therapeutic purposes when medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare and Plan rules to determine if the Plan was correct in denying the request to pre-approve 4 additional acupuncture visits. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee has severe arthritis of her hands and neck pain. The enrollee reports significant pain relief. The progress note speaks to neck pain. There is well founded evidence for treatment of arthritis and neck pain with acupuncture. The documentation provided supports that the additional acupuncture visits being requested are medically necessary and should be covered under the Plan's supplemental acupuncture benefits.  We looked at this physician's review, the file, Medicare rules, and Plan contract rules. Based on this information, we decided that the Plan's rules for coverage of 4 additional acupuncture visits have been met. Therefore, we decided that the Plan has to pre-approve 4 additional acupuncture visits.   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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the detailed and extensive oral evaluation (D0160), periodontal maintenance (D4910), limited oral evaluation (D0140), periapical x-ray (D0220), inhalation of nitrous oxide (D9230), osseous surgery (D4261), and occlusal adjustment (D9951) provided from June 28, 2021, to August 24, 2021, by an out of network dentist.  

You asked the Plan to pay for the dental services. You say that you need these services to be covered. You also say that you know that the dentist is not in network. The Plan denied your request. The Plan says dental services received out of network are not covered. The Plan also says that you contacted them for a list of in network providers, but not until after you had already received the services. 

 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 dental services you received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the detailed and extensive oral evaluation (D0160), periodontal maintenance (D4910), limited oral evaluation (D0140), periapical x-ray (D0220), inhalation of nitrous oxide (D9230), osseous surgery (D4261), and occlusal adjustment (D9951) provided from June 28, 2021, to August 24, 2021, by an out of network dentist.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the X-ray services (71045) provided on September 7, 2021.  

You asked the Plan to pay for the X-ray services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier as required by Medicare rules.  

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, we have confirmed that code 71045 is a column II code to column I code 71046. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the X-ray services (71045) provided on September 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI scan of the brain (70553) provided 
on July 13, 2021.

You asked the Plan to waive the copayment for an MRI scan of the brain. You say that no one warned you that 
an MRI scan has a different copayment. The Plan denied your request. The Plan says the correct copayment 
was 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 $250 
copayment for diagnostic radiology other than computed tomography (CT) scans. 

You have been asked to pay a $250 copayment for an MRI scan of the brain. an MRI scan of the brain 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 copayment for an MRI scan of the brain (70553) provided on July 13, 2021.

Your complaint about not being told in advance about your cost-sharing responsibilities for an MRI scan is not 
a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pontic porcelain/ceramic on tooth #5 and tooth #6 (D6245) and one unspecified adjuntive procedure (D9999) to be provided by an out-of-network (OON) provider. 

 You asked the Plan to pre-approve dental services. You say that you keep biting your lips and the inside of your mouth because you do not have any teeth in the front. You also say that you have to chew on one side because of the missing teeth. The Plan denied your request. The Plan says this is not a covered benefit under your Plan. The Plan also says that you receive a discount on dental services when you see a participating network provider. 

 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 dental services when you visit a participating dental network provider. 

 We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. Specifically, you must visit a participating dental network provider to receive dental benefits. Therefore, we decided that the Plan does not have to pre-approve a pontic porcelain/ceramic on tooth #5 and tooth #6 (D6245) and one unspecified adjuntive procedure (D9999) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on December 21, 2020.  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 the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on May 21, 2021.  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 there is no valid physician order.  The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.   We looked at the file and Medicare rules. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 21, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) services.  You asked the Plan to pre-approve the MRI. You say that the records provided support the medical necessity of an MRI. The Plan denied your request. The Plan says that the records do not show the results of an x-ray taken after the enrollee's symptoms started or changed, that show a need for further imaging.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 the MRI. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee has no point tenderness on physical exam.  The working diagnosis of tenosynovitis and tendinitis is best imaged by MRI. Plain films would offer no additional diagnostic yield and, even if normal, would not obviate the need for MRI.  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 MRI have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) services.   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.