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

We decided that the Plan does not have to pre-approve external cardiac monitor.
You asked the Plan to pre-approve external cardiac monitor. You say that this is medically necessary. The Plan
denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that an external cardiac monitor is subject to the criteria
listed 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 external cardiac monitor. Our reviewer
says that the requested device is not medically reasonable and necessary. Our physician reviewer found the
patient has palpitations and documented Premature ventricular contractions (PVCs) on office electrocardiogram
(ECG). There is no supportive evidence that the ordering practitioner documented any standard, non-mobile
cardiac outpatient telemetry, ambulatory ECG monitoring. In summary, there is insufficient documentation to
support the medical necessity for a mobile cardiac outpatient telemetry monitor in this patient's clinical
management.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of external cardiac monitor have not been met. Therefore, we decided that the Plan
does not have to pre-approve external cardiac monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May
2, 2021, to May 19, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the
charges and request the Plan's assistance with the matter. 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 (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $345
copayment for days 1-5 for inpatient hospital care.
You received inpatient hospital care from May 2, 2021, to May 19, 2021. Therefore, you are responsible to pay
a $345 copayment for days 1-5 (May 2, 2021, to May 6, 2021). The total amount you owe is: $345
(copayment) x 5 (inpatient days) = $1,725.
You have been asked to pay the total copayment amount of $1,725 for inpatient hospital care. Inpatient hospital
care 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 inpatient hospital care provided from May 2, 2021, to May
19, 2021.
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 enrollee cannot dress or walk by herself. The Plan denied your request. The Plan says the enrollee does not need an intensive team for care.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for an aortic valve replacement. Her medical problems are stable. The complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.  You asked the Plan to pre-approve the continuation of SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.  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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. The enrollee does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. However, based on the medical records provided daily skilled services are not required. The enrollee has shown little objective improvement in function over her three-week course in the nursing facility receiving daily services; at this point part-time services appear indicted. Based on the medical records provided this enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting.  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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling for tooth # 4 provided on October 5, 2021.
You asked the Plan to pay for the dental service. You say that you were advised by a plan representative that
you could go to this office. You say that this office takes your insurance but is not a preferred provider. You
say that you feel you were sent to the wrong office so that the plan could save money. You also say that the
services should be covered as in network.
The Plan denied your request. The Plan says 2 fillings are covered per year. The Plan says that the frequency
limit has been exceeded. The Plan also says that out of network dentists may bill you for any amount greater
than what the plan pays.
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 fillings are listed as covered, the
frequency limit has been exceeded. The record shows that the Plan paid the allowed amount for 2 fillings you
received on the date of service in this case. Additionally, out of network dentists may bill you for any amount
greater than what the plan pays. Therefore, we decided that the Plan does not have to pay for the filling for
tooth # 4 provided on October 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for modified barium swallow (74230) provided August 16, 2021.
You asked the Plan to pay for the diagnostic service. You say that this enrollee requires supervision and has difficulty being transported. There were no contracted providers that could have provided this service. The Plan denied your request. The Plan says this service is not a covered benefit.
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. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for modified barium swallow (74230) provided August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), fluoride varnish (D1206 x 2), adjunctive pre-diagnostic test (D0431), scaling and root planing (D4342 x 4), and localized delivery of antimicrobial agents (D4381 x 5) provided from April 22, 2021, to April 29, 2021.  You asked the Plan to pay for the dental services. You say that you found this provider on the plan's website. You say that you paid for the services that were not covered. You also say that you were advised the services would be reprocessed as in network. The Plan denied your request. The Plan says the provider in this case is out of network at the location you received the services. The Plan also says that complete series x-ray, fluoride varnish, adjunctive pre-diagnostic test, and localized delivery of antimicrobial agents are not listed as covered 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 complete series x-ray, fluoride varnish, adjunctive pre-diagnostic test, and localized delivery of antimicrobial agents are not among those covered under this benefit. Additionally, out of network providers may bill you for any amount greater than what the plan pays. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), fluoride varnish (D1206 x 2), adjunctive pre-diagnostic test (D0431), scaling and root planing (D4342 x 4), and localized delivery of antimicrobial agents (D4381 x 5) provided from April 22, 2021, to April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit with diagnostic services (76830, 81003, 99204, 36415) provided on September 13, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit with diagnostic services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.  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 an office visit with diagnostic services (76830, 81003, 99204, 36415) provided on September 13, 2021, 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 retainer crowns (D6750) and pontic (D6240) provided on
August 31, 2021.
You asked the Plan to pay for the dental services. You say that when you signed up for this plan, you were told
that these services would be covered. The Plan denied your request. The Plan says these services are not
covered by your dental benefit. The Plan also says that they are addressing your other concerns in a separate
grievance case.
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 the
retainer crowns (D6750) and pontic (D6240) provided on August 31, 2021.
Your complaint about potential misinformation from a Plan representative 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Minuteman interspinous device.  You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative treatment. The Plan denied your request. The Plan says the clinical effectiveness has not been demonstrated in peer reviewed literature.  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 requested services. Our physician reviewer found that the requested device is experimental. More research is needed to show its safety and efficacy. Therefore, the device is not considered medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Minuteman interspinous device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crowns (D6740 x 2), pontic (D6245) provided on
September 14, 2021.
You asked the Plan to pay for the dental services. You say that your tooth was severely infected. You say that
you had a bridge to replace the tooth. You also say that you would like these services to be covered. The Plan
denied your request. The Plan says the maximum allowance 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 maximum allowance of $2,000 for
covered dental services has been exhausted.
Date of Service Plan Paid
1/7/2021            $239
1/25/2021          $286
7/15/2021           $133
9/14/2021           $1,342
TOTAL: $2,000
Additionally, you are responsible for any amount above the dental coverage limit. Therefore, we decided that
the Plan does not have to pay for the retainer crowns (D6740 x 2), pontic (D6245) provided on September 14,
2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a hip injection provided on May 4, 2021.  You asked the Plan to waive the copayment for the injection. You say that you thought the injection would be included in your primary care copayment. 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 $195 copayment for surgery or other services provided to you at an ambulatory surgical center. Ambulatory surgical center facilities are designated as Type 1 in the provider directory.   The facility in which the procedure was performed is listed as Type 1 in the directory. Therefore, you have been asked to pay a $195 copayment for the injection. The injection falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 hip injection provided on May 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive interface (e.g., mask, chest shell) (E0466).  You asked the Plan to pre-approve the ventilator. You say that with the enrollee's need for continuous oxygen, he meets Medicare's guidelines for non-invasive ventilator due to hypoxia. He has been on CPAP therapy and could not tolerate it and returned it. The Plan denied your request. The Plan says ventilators used to provide CPAP or bi-level Pap therapy are not covered by Medicare.  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 ventilator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee has COPD with frequent exacerbations. An arterial blood gas shows mild CO2 retention.  The enrollee has been unable to tolerate NIV via face mask because of claustrophobia, and therefore would not be able to tolerate BiPAP via face mask. The Life2000 System is not a true ventilator because it is not capable of providing full ventilatory support. It is intended to provide support during activity. There are no controlled trials establishing its efficacy in the treatment of COPD. The Life2000 System 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive interface (e.g., mask, chest shell) (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established
patient (D0150) provided September 29, 2021.
You asked the Plan to pay for the comprehensive oral exam. You say that you found a new dentist because you
received poor service from your previous dentist. The Plan denied your request. The Plan says you have
exceeded the frequency limit for this service.
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
comprehensive oral exam once every three years.
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive
exam was previously covered on March 29, 2021.
Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral
exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral
evaluation - new or established patient (D0150) provided September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 17,
2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you did not receive this service
on this date of service. 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 (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $10
copayment for specialist visits.
The medical records show that you received specialist services on August 17, 2021. Therefore, you are
responsible to pay the $10 copayment.
You have been asked to pay a $10 copayment for a specialist visit. A specialist visit falls 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 visit provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or home visit (99335) provided on April 9, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a domiciliary or home visit. You say that the provider has no prior knowledge of which patients he will be required to see. You also say that once he arrives at the facility, he receives a list of patients who require psychiatrist care, and he must provide services to all of them since there is currently no in-network doctor who can treat the patients in this facility. The Plan denied your request. The Plan says an authorization was not obtained prior to the services being rendered and the provider is not participating with the member's Plan. The Plan also says that it was determined the services were not urgent or emergent in nature.
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 a domiciliary or home visit (99335) provided on April 9, 2021, by an out-of-network (OON) provider.