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

We decided that the Plan does not have to pre-approve a Volara System (E1399).
You asked the Plan to pre-approve the Volara therapy system. You say that the device is necessary. The Plan denied your request. The Plan says there is not enough information that is published about this device; therefore, it is experimental and not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our 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 Volara therapy system. Our reviewer says that the requested items/services are not considered reasonable and necessary in this case. Our reviewer found this device does not meet Medicare coverage criteria. This device is experimental, investigational and does not have a defined code; there are different types of oscillating devices that the enrollee may be covered for.
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 Volara therapy system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Volara System (E1399).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on June 25, 2021.

You asked the Plan to waive the copayment for a diagnostic mammogram. You say that your doctors want you to have a diagnostic mammogram instead of a screening mammogram on a yearly basis for the next seven years. You also say that the diagnostic mammogram should be treated as a screening mammogram and be fully covered. 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 an $80 copayment for each outpatient hospital visit for diagnostic tests.

You have been asked to pay an $80 copayment for a diagnostic mammogram. Diagnostic mammograms fall within the Outpatient Diagnostic Tests, 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 a diagnostic mammogram provided on June 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on April 23, 2021.
You asked the Plan to pay for the self-administered drugs. You say that You were given 2-3 nitro pills by nurses in the ER for chest pain and discomfort. You say that you did not have any self-administered drugs and want a review of the amount. The Plan denied your request. The Plan says these services are not covered by Medicare.
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 on April 23, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services provided by a participating provider on January 5, 2021, to May 4, 2021.

You asked the Plan to waive the copayment for podiatry services. You say that you do not agree with these copayments. The Plan denied your request. The Plan says the correct copayments have 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 $40 copayment for podiatry services/podiatry services. 

You have been asked to pay a $40 copayment for podiatry services. The total amount you are being asked to pay is $120 ($40 x 3 visits = $120). The correct copayment has been applied to the services that were provided. Podiatry services fall within the podiatry services/podiatry services 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 podiatry services provided by a participating provider on January 5, 2021, to May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for periodontal scaling and root planing in the upper right quadrant provided on March 3, 2021.
You asked the Plan to pay for periodontal scaling and root planing in the upper right quadrant. You say that you should be able to get one periodontal scaling and root planing effective January 2021 and every three years after. You say that prior years should not be considered. The Plan denied your request. The Plan says that periodontal scaling and root planing is only allowed one procedure every three calendar years.
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 periodontal scaling and root planing once every three years per quadrant when the services are medically necessary and reasonable.
The Plan says that the periodontal scaling and root planing is not covered because the frequency limit has been met. The records show the periodontal scaling and root planing provided on June 24, 2019 was for the upper left quadrant. The periodontal scaling and root planing provided on March 3, 2021 was for the upper right quadrant. The Plan contract clearly says periodontal scaling and root planing is covered once every three years per quadrant. Therefore, we decided that the Plan has to pay for periodontal scaling and root planing in the upper right quadrant provided on March 3, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 11, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. You say that the rendering physician is a hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtained prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained for these services.

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 provided on December 11, 2020 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have not been met. 

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that you have stabilized medically and is ready 
for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily 
basis. You are medically stable and can receive further rehab services at a lower level of care. Although further 
rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services 
can be provided at a lower level of care than a skilled nursing facility. You do not have any parental 
medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any 
acute exacerbations of chronic medical problems. His physical function is at or near his baseline and he can 
receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve 14 additional home health visits.
You asked the Plan to pre-approve 14 additional home health visits. You say that the services are necessary.
The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has
not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 14 additional home health visits. Our
reviewer says that the services are medically necessary. Our physician reviewer found while ambulatory, you
are noted to be homebound. While shallow, you are noted to have multiple lower extremity wounds. The
wounds require thrice weekly care, which you and your caregivers are currently unable to provide properly.
Home health skilled nursing services are medically necessary to dress the wounds and provide wound care
teaching. The health plan has failed to show that you are not homebound, that you or caregiver can tend to the
wounds, or that an adequate outpatient and/or self-wound care program is available.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 14 additional home health visits have been met. Therefore, we decided that the
Plan has to pre-approve 14 additional home health 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on July 8, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there is no referring provided.
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 provided on July 8, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on September 4, 2020 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that these services were medically necessary. You 
say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior 
authorization was not obtained for these services. The Plan says that the member's primary care physician did 
not refer these services. 
 
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 chiropractic services provided on September 4, 
2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 20, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. You say that the rendering physician is a hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtained prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 provided on November 20, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency oral evaluation (D0140) and pay an additional amount for the root canal (D3330) provided on May 5, 2021.
You asked the Plan to pay for the dental services. You say that you received a denial for your claim for a root canal. You say that you were advised by a plan representative that this service would be covered. You also say that you do not understand how you have exceeded the frequency limit for the oral evaluation. The Plan denied your request. The Plan says 1 emergency oral evaluation problem focused exam is covered every 12 months. The Plan says that the frequency limit for this service has been exceeded. The Plan also says that there is a 50% coinsurance for Class 3 Major Services, including a root canal.
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 and the emergency oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for an emergency oral evaluation that you received on May 4, 2021. Additionally, the Evidence of Coverage clearly states that there is a 50% coinsurance for Class 3 Major Services, including a root canal. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay for the emergency oral evaluation (D0140) and pay an additional amount for the root canal (D3330) provided on May 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from March 26, 2021, to April 1, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the doctor previously made an error causing the hospital stay to be necessary and you should not be responsible for the cost. The Plan denied your request. The Plan says the copayment was applied correctly. Your quality-of-care concerns regarding the provider error is being addressed separately.
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 $290 copayment for Inpatient hospital care.
You have been asked to pay a total of $1,450 ($290 copayment x 5 days = $1,450) for the inpatient hospital stay. This service falls within the Inpatient hospital care 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 the inpatient hospital stay from March 26, 2021, to April 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced foot feature (L5986).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is denied as it is miscoded.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you were approved for the K3 L5984 endoskeletal axial rotation foot. The requested foot is a Rush Roque 2 which is coded as L5987 + L5984. The L5986 multiaxial rotation unit is not the correct code for the requested foot, and therefore is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced foot feature (L5986).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 15, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. 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 the services provided by an out-of-network provider on January 15, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0427, A0425) provided on January 15, 2021.
You asked the Plan to waive the copayment for the ambulance transportation services. You say that you did not know you had to pay a copayment for this service. The Plan denied your request. The Plan says this claim was processed correctly, and the cost-sharing for this service was applied in accordance with your 2021 Plan contract.
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 $150 copayment for ambulance services. You have been asked to pay a $150 copayment for the ambulance transportation services. 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 emergency ambulance transportation services (A0427, A0425) provided on January 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0482) provided on May 3, 2021.
You asked the Plan to pay for the lab 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 services at issue in this appeal. The Plan did not pre-approve the service 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 lab services (G0482) provided on May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 3, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services provided on November 3, 2020