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

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on August 24, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you were not advised that this provider did not accept your insurance, and you feel it is no fault of your own. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.

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 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on August 24, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with an orthopedic surgeon on September 13, 2021.

You asked the Plan to waive the copayment for the orthopedic surgery visit. You say that this copayment should be waived because it was still within the 'global' office visit time frame because the office told me it
would be covered as a follow-up. You said that you had a total knee replacement and this was your third follow-up visit. The Plan denied your request. The Plan says you were charged this copayment 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 $30 copayment for specialist visits. 

You have been asked to pay a $30 copayment for the orthopedic surgery visit. Medicare rules state that follow-up visits that occur during the postoperative period are not separately payable. This postoperative period can last up to 90 days, depending on the complexity of the surgery you had. The knee replacement surgery you had on March 10, 2021, has a 90-day global postoperative period. The follow-up visit you had on September 13, 2021, is outside of this 90-day period, so separate cost sharing can apply. 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 office visit you had with an orthopedic surgeon on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on August 19, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you never used your benefit for this service. The Plan denied your request. The Plan says your annual maximum benefit has been exhausted.

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 Plan offers a $2,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit while processing this claim for the August 19, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on August 19, 2021.
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 that you continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility. The documentation does not support that an additional 25 days of hospitalization are reasonably expected.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on March 16, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The 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 to the enrollee on March 16, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for psychotherapy telehealth visits you had from April 30, 2021, to June 15, 2021.

You asked the Plan to waive the copayments for the psychotherapy telehealth visits. You say that you do not believe a copayment should apply to these services. The Plan denied your request. The Plan says you were charged these copayments 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 $40 copayment per visit for outpatient mental health telehealth services. 

You have been asked to pay a $40 copayment per visit for the psychotherapy telehealth visits. 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 copayments for psychotherapy telehealth visits you had from April 30, 2021, to June 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ingrezza for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Ingrezza for the enrollee.

Benefits for this 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $225 copayment charged for transfer from one facility to another on September 11, 2021.

You asked the Plan to waive this copayment. You say that the hospital told you this would be covered. The Plan denied your request. The Plan says the transport was covered however requires cost share.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says that you must pay $225 copayment for each one-way ambulance transport. 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 $225 copayment charged for transfer from one facility to another on September 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network physician services provided on March 30, 2021.

You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.

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 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 out of network physician services provided on March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the One Touch Ultra Test Strips.

You asked the Plan to pre-approve the One Touch Ultra Test Strips. You say that the item is medically necessary. The Plan denied your request. The Plan says that the item is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 One Touch Ultra Test Strips. Our reviewer says that the requested items are considered medically reasonable and necessary in this case. Our physician reviewer found you are unable to see the results on your current meter and the requested test strips have a larger screen for you to see the numbers. 

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 One Touch Ultra Test Strips have been met. Therefore, we decided that the Plan has to pre-approve the One Touch Ultra Test Strips.

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 pre-approve an unspecified fixed prosthodontic procedure (D6999 x2).

You asked the Plan to pre-approve an unspecified fixed prosthodontic procedure. You say that the service at issue is medically necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an unspecified fixed prosthodontic procedure (D6999 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from December 29, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from December 29, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care from December 29, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of December 29, 2021, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond December 29, 2021, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. 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 psychiatric care from December 29, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from December 29, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block.
You asked the Plan to pre-approve genicular nerve block. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because genicular nerve blocks are considered experimental/investigational.
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 genicular nerve block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and radiofrequency ablations are considered investigational for the treatment of chronic knee pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's condition has improved, and is no longer a threat to himself or others.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 admission is not medically reasonable or necessary. Our physician reviewer found the request for ongoing acute inpatient care is not medically reasonable or necessary. The enrollee was calm and cooperative, his mood was stable and he had no thoughts to harm himself or others, he was not hearing voices telling him to harm himself or others, he had no verbal or physical aggression, he was compliant with medication and had no side effects. The enrollee was participating in treatment, he was sleeping and eating well, and was able to perform activities of daily living and had no acute symptoms requiring 24 hour inpatient care. 

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 admission to an inpatient psychiatric facility for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental bridges and a pontic provided on February 11, 2021.

You asked the Plan to pay for dental bridges and pontic. You say that you were sent a fax from the Plan stating that bridges were covered. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by the Plan's dental benefits.

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 dental bridges and a pontic provided on February 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for lab services provided from January 8, 2021, to May 27, 2021.

You asked the Plan to waive the copayments for the lab services. You say that you never consented to being enrolled in this plan and you wanted your Original Medicare coverage reinstated. The Plan denied your request. The Plan says these copayments were charged correctly. The Plan says that for each date of service, the allowed amount is less than your copayment obligation, so you are responsible for the full allowed 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 $15 copayment for each lab service. 

You have been asked to pay a $15 copayment for the lab services. the lab services falls within the each lab service 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 copayments for lab services provided from January 8, 2021, to May 27, 2021.

The Qualified Independent Contractor read your letter and knows that you may have a question regarding your enrollment in the Plan. The QIC cannot answer enrollment questions. The QIC is sending a copy of your case file and your letter to a CMS Regional Office so that it can look into your enrollment question.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nurtec ODT for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Nurtec ODT for the
enrollee.
Please note, the Plan has confirmed that this drug is begin covered under the enrollee's Medicare Part D plan.
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 pre-approve a surgical extraction (D7210) for tooth # 10.

You asked the Plan to pre-approve the dental service. You say that the service is necessary. The Plan denied your request. The Plan says a surgical extraction for tooth # 10 is not necessary.

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 dental service 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 dental service. Our reviewer says that the surgical extraction of tooth # 10 is not medically necessary. Our physician reviewer found the requested code, D7210, requires that to remove the tooth in question that there must be cutting of bone. The reviewer found that in this instance, there is a single rooted tooth, essentially intact, with a significant amount of the supporting bone missing from around the tooth that would make removal easier and even less likely to require removal of bone to extract the tooth. Given the documentation provided, there is no clear need for removal of bone to extract tooth # 10.

Therefore, the reviewer found that the requested surgical extraction is not medically reasonable or necessary. 

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 dental service have not been met. Specifically, the file shows that there is no clear need for removal of bone to extract tooth # 10. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction (D7210) for tooth # 10.