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

We decided that the Plan does not have to pay more for the problem focused limited oral evaluation, first
intraoral periapical x-ray, and six resin-based composites provided on April 13, 2021, and May 17, 2021, by an
OON provider.
You asked the Plan to pay more for the problem focused limited oral evaluation, first intraoral periapical x-ray,
and resin-based composites. You say that this provider advised that you needed six fillings, gave you
paperwork, and advised that your insurance would cover $1,424.00. You also say that nothing was paid
towards these bills by the Plan. The Plan denied your request. The Plan says the treating provider does not have
a contract with your plan and is allowed to bill the difference of the allowed amount and billed amount.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference
between the billed amount and allowed amount for dental services received OON. Therefore, we decided that
the Plan does not have to pay more for the problem focused limited oral evaluation, first intraoral periapical xray,
and six resin-based composites provided on April 13, 2021, and May 17, 2021, by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on March 31, 2021.
You asked the Plan to pay for the physical therapy. You say that the appeal should be reviewed and authorization should be provided. The Plan denied your request. The Plan says prior authorization for out-of-network services was required but not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on March 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the interspinous implant.
You asked the Plan to pre-approve the interspinous implant. You say that you would like reconsideration because the requested procedure is medically necessary. The Plan denied your request. The Plan says this procedure has not been shown to be helpful for the member's condition.
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 interspinous implant. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinus distraction devices are experimental and more research is needed to show their safety and efficacy.
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 interspinous implant have not been met. Therefore, we decided that the Plan does not have to pre-approve the interspinous implant
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the blood glucose strips (A4253) and lancets (A4259).
You asked the Plan to pre-approve the blood glucose strips and lancets. You say that the items are medically necessary. The Plan denied your request. The Plan says the enrollee did not have insulin use.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not insulin-treated with multiple (three or more) daily administrations. Based on this information, we decided that Medicare rules for coverage of the blood glucose strips and lancets have not been met. Therefore, we decided that the Plan does not have to pre-approve the blood glucose strips (A4253) and lancets (A4259).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from December 18, 2020, to December 25, 2020.
You asked the Plan to waive the copayment for the inpatient care. You say that the enrollee was initially brought to a Plan facility, but then was told that they were not receiving patients at that time due to the pandemic. The enrollee was then brought to another facility at the direction of the Plan, which was not your choice, and you feel the enrollee should not owe this copayment as they are receiving active financial help from the Plan. The Plan denied your request. The Plan says the claim was processed correctly and in accordance with the enrollee's contract. There is a $235 copayment per day for inpatient hospital care up to 7 days.
A lesser amount was billed because the enrollee met their $4,000 annual out-of-pocket maximum. The financial assistance program is not a benefit program. The program limits eligibility for financial assistance to enrollee's receiving medically necessary care provided only in a Plan facility. The services at issue were provided by a non-Plan facility.
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 $235 copayment for each of the first seven days of an inpatient hospital stay in your county. As a member of the Plan, the most an enrollee will have to pay out-of-pocket for in-network services is $4,000 for your area. If the maximum out-of-pocket amount is reached, the enrollee will not have to pay any out-of-pocket costs for the rest of the year. The enrollee has been asked to pay a $774 copayment for the seven-day inpatient stay. The full copayment does not apply because the enrollee met the out-of-pocket maximum at this time. 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 inpatient hospital admission and services provided from December 18, 2020, to December 25, 2020.
Your complaint about potentially being directed by the Plan to use a non-Plan facility and then being ineligible for financial assistance 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for x-rays provided on April 27, 2021.

You asked the Plan to waive the deductible for x-rays. You say that you met the deductible amount prior to
receiving the services. 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. Your
contract with the Plan says that there is a $500 deductible which applies to outpatient diagnostic tests and
therapeutic services and supplies.

The record shows that you had paid $0 toward the $500 deductible prior to receiving x-rays on April 27, 2021.
Therefore, you are responsible to pay the allowed amount of $35.72.

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $500 deductible which applies to outpatient diagnostic tests and
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time
x-rays was received on April 27, 2021. Therefore, we decided that the Plan does not have to waive the
deductible for x-rays provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.
You asked the Plan to pre-approve the requested services. You say that the medial branch blocks were successful in eliminating 50% of her pain. The Plan denied your request. The Plan says the enrollee did not have pain relief of greater than 80%.
The Plan must follow Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications. We looked at the file and Medicare rules. We find that the services are not indicated for coverage. Specifically, the records do not show that the enrollee experienced pain relief for a sustained period of time. 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 radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), an intraoral complete
series of radiographic images (D0210), and a teeth cleaning (D1110) provided on March 8, 2021.

You asked the Plan to pay for a periodic oral evaluation, an intraoral complete series of radiographic images,
and a teeth cleaning. You say that you were not aware that the provider was out-of-network. The Plan denied
your request. The Plan says you are not covered for these services when seen by an out-of-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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a periodic oral evaluation, an intraoral complete series of radiographic images, and a teeth cleaning
have not been met. Specifically, services were provided by an out-of-network provider without prior
authorization. The Plan has contracted providers available to provide these services. 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 a periodic oral evaluation (D0120), an intraoral complete series of radiographic images (D0210), and a teeth
cleaning (D1110) provided on March 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve service dog supplies using the Service Dog Support
benefit.
You asked the Plan to pre-approve service dog supplies. You say that you have a disability and chronic
condition. The Plan denied your request. The Plan says after several attempts they were unable to confirm that
you meet the requirements for the Service Dog Benefit or if you have a service dog.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. There is no documentation on the dog and the Plan was unable to
speak with you. Based on this information, we decided that Medicare rules for coverage of service dog supplies
have not been met. Therefore, we decided that the Plan does not have to pre-approve service dog supplies using
the Service Dog Support benefit
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the portable home ventilator.
You asked the Plan to pre-approve the portable home ventilator. You say that you would like reconsideration because this equipment is necessary to treat your COPD with chronic respiratory failure. The Plan denied your request. The Plan says the requested device would be used in a BiPAP mode that could be provided in with a BiPAP device.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 portable home ventilator. Our reviewer says that Medicare does not cover a home ventilator when used as BiPAP. Our physician reviewer found there is no documentation of BiPAP failure, but the medical records indicate that you do not meet the minimum requirements for use of the device.
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 portable home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the portable home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) receiver (K0554)
and supplies (K0553).
You asked the Plan to pre-approve a CGM receiver and supplies. You say that the items are medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested
items.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood
glucose testing results, and have had an in-person visit with their treating physician to assesses adherence to
their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for
coverage of a CGM receiver and supplies have not been met. Therefore, we decided that the Plan does not have
to pre-approve a continuous glucose monitor (CGM) receiver (K0554) and supplies (K0553).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99232) provided from February 19, 2020, to February 25, 2020.
You asked the Plan to pay for hospital care. You say that this should not be included because it was performed by the assistant surgeon. The Plan denied your request. The Plan says this is included in the global surgical package.
The Plan must follow Medicare rules. Medicare rules say that follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery are included in the Medicare approved amount for procedures with the appropriate entry in Field 16 of the Medicare Fee Schedule Data Base (MFSDB).
We looked at the file and Medicare rules. The records show that the services at issue were follow-up care provided during the 90-day post-operative period of a small intestine removal surgery. These services are therefore included in the global surgical package. Based on this information, we decided that Medicare rules for coverage of hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99232) provided from February 19, 2020, to February 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services provided on March 17, 2021.

You asked the Plan to pay for critical care services. You say that the attached medical record contains a detailed account of the history, examination and medical decision making provided to this patient. You say that the documentation supports the level of care billed and is payable as coded. The Plan denied your request. The Plan says the documentation does not include the time spent providing this service; therefore, the billed critical care evaluation and management code cannot be verified.

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 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes.

We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted
does not indicate the amount of time spent rendering the critical care services. Based on this information, we
decided that Medicare rules for coverage of critical care services have not been met. Therefore, we decided that
the Plan does not have to pay for critical care services provided on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2303, V2750) purchased on May 11, 2021.

You asked the Plan to pay for the eyeglasses. You say that these glasses should be covered as they were your first claim for eyewear this year and you have a $150 allowance. The Plan denied your request. The Plan says they have paid the full $150 allowance and you are responsible for the remaining cost. The Plan has paid their share, but the additional amount due is denied.

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 up to $150 for routine corrective eyewear every calendar year. If the eyewear purchase costs more than the Plan's allowance, you pay the difference. 

We looked at the file and the Plan's rules. The eyewear purchased on May 11, 2021, was billed for a total of $249. Documentation shows that the Plan paid $150, and you are asked to cover the remaining $99 of the cost on this claim. You met and exceeded your limit on the date in question, and the Plan has only denied payment of the remaining $99 amount. Based on this information, we decided that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay any additional amount for the eyeglasses (V2303, V2750) purchased on May 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox for the enrollee.
You asked the Plan to pre-approve Botox. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that there is no approved labeled indication for treatment of salivary
secretions.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Botox. Our reviewer says that Botox is
not medically reasonable and necessary for the enrollee in this case. There is no documentation that the
requested use of Botox is Food and Drug Administration-approved for the enrollee's diagnosis of
sialorrhea/excessive salivation in the setting of cerebral palsy. There is no documentation that off-label use for
Botox is supported for the enrollee's diagnosis of sialorrhea/excessive salivation in the setting of cerebral palsy.
Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Botox.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to
pre-approve Botox for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve additional trips. You say that you need rides to get to your medical appointments. The Plan denied your request. The Plan says your benefit covers 24 trips for this service.

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 a maximum of 24 one-way trips per year.

We looked at your request, the records in the case file, and the rules. The records show that you have used 24 trips this year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.