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

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 11, 2021.  You asked the Plan to pay for the comprehensive oral evaluation. You say that you were not satisfied with the services and professionalism rendered by your previous provider, so you found another dentist. You also say that the new dentist had to do an exam because you were a new patient, and you feel an exception for coverage should be made. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.  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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on January 18, 2021 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (64415) provided on August 10, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 64415 is a column II code to column I code 01630. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (64415) provided on August 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area (CPT code 15271), Grafix core and grafixpl core, per square centimeter (CPT code Q4132), and Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter and (CPT code Q4133), for the enrollee.  You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says there is no medical necessity for Grafix Prime.  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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has received treatment at a wound care clinic and at home with skilled services. Per the reviewed documentation at follow-up February 2, 2022, and February 9, 2022, wounds are smaller and improving slowly. There is no specific clinical rationale for the use of Grafix as the wounds are improving with the present wound care therapy. The review has determined that the items/services at issue in this case are not 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area (CPT code 15271), Grafix core and grafixpl core, per square centimeter (CPT code Q4132), and Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter and (CPT code Q4133), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for hospital outpatient clinic visits (G0463) and tangential biopsies of the skin (11102) rendered from June 30, 2021, to July 15, 2021.  You asked the Plan to waive the copayment for hospital outpatient clinic visits and tangential biopsies of the skin. You say that you have already met your out of pocket limit for the year, and since you have already paid out of pocket $2,000 for the year as of August 3, 2021, if you pay this you would be paying $2,200 and not $2,000. The Plan denied your request. The Plan says you were 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 $100 copayment per facility visit for outpatient hospital services.    You have been asked to pay a $100 copayment per facility visit for hospital outpatient clinic visits and tangential biopsies of the skin. Hospital outpatient clinic visits and tangential biopsies of the skin falls within the outpatient hospital services benefit category. The records show that the $2,000 out of pocket expense was met as of August 31, 2021. 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 hospital outpatient clinic visits (G0463) and tangential biopsies of the skin (11102) rendered from June 30, 2021, to July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for chiropractic services provided on September 23, 2021.  You asked the Plan to waive the copayment for the chiropractic services. You say that you feel that the X-rays from the provider should be paid. 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 $20 copayment for chiropractic services received in a specialist office.   We looked at the file. There is no evidence that shows that X-rays were performed or billed. According to your explanation of benefits (EOB), the service performed and charged was for the chiropractic manipulative treatment. Therefore, you have been asked to pay a $20 copayment for the chiropractic services. The chiropractic services falls within the Chiropractic 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 chiropractic services provided on September 23, 2021.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve use of Supartz.  You asked the Plan to pre-approve Supartz. You say that your physician believes you would respond well to Supartz and does not use other drugs. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the Plan requires a trial of Euflexxa or Durolane before it will approve Supartz.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Your contract with the Plan does not support that step therapy criteria have been implemented for the health plan in which you are enrolled. Therefore, the Plan has not shown that you are contractually obligated to try Euflexxa or Durolane before you can use Supartz. The Plan has not provided any other rationale to support a denial of Supartz. Therefore, the Plan has not shown that its decision to deny authorization for this drug is correct or justified according to Medicare rules and your contract with the Plan. Therefore, we decided that the Plan has to pre-approve use of Supartz.   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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services, hospital outpatient clinic visit, and magnetic resonance imaging (MRI) of the brain provided on August 31, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory services, hospital outpatient clinic visit, and MRI of the brain. You say that you are on a fixed income and cannot afford to pay for these services. The Plan denied your request. The Plan says the services were not rendered or referred by a network provider. The Plan also says 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 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 the laboratory services, hospital outpatient clinic visit, and magnetic resonance imaging (MRI) of the brain provided on August 31, 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 scaling and root planing (D4341) for the upper right quadrant provided on November 9, 2021.  You asked the Plan to pay for the dental service. You say that you have not had a deep cleaning on your teeth in the last 2 years. You also say that you had received a letter saying these services were approved. The Plan denied your request. The Plan says scaling and root planing is covered once per quadrant every 2 years. The Plan also says that the frequency limit has been exceeded.  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 service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for scaling and root planing for the upper right quadrant that you received on November 4, 2021. Therefore, we decided that the Plan does not have to pay for the scaling and root planing (D4341) for the upper right quadrant provided on November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on April 22, 2021.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not a covered screening test.  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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for radiation oncology treatment provided by a network provider from August 27, 2021, to August 31, 2021.  You asked the Plan to waive the coinsurance for the radiation oncology treatment. You say that you told the office that you cannot afford to pay for treatment. The Plan denied your request. The Plan says you have been asked to pay 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 20% coinsurance for the cost of therapeutic services.   You have been asked to pay $175.17 which is 20% of the allowed amount for the radiation oncology treatment. The allowed amount is $875.86. ($875.76 x 20% = $175.17). The radiation oncology treatment falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for radiation oncology treatment provided by a network provider from August 27, 2021, to August 31, 2021.   Your complaint about fraud is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140), bitewing x-ray (D0270), panoramic x-ray (D0330), and office visit for observation (D9430) provided from October 4, 2021, to October 7, 2021.  You asked the Plan to pay for the dental services. You say that you were experiencing a strong pain in your tooth. You also say that you were not aware that visits for problem teeth were not allowed. The Plan denied your request. The Plan says office visit for observation is not listed as a covered service. The Plan also says that the frequency limits for the limited oral evaluation, bitewing x-ray, and panoramic x-ray have been exceeded.  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 limited oral evaluation, the office visit for observation is not among those covered under this benefit. Additionally, bitewing x-ray, and panoramic x-ray are listed as covered, but the frequency limits have been exceeded. The Evidence of Coverage (EOC) says that a limited oral evaluation and bitewing x-rays are covered once per plan year. The EOC says that a panoramic x-ray is covered once every 3 plan years. The record shows that the Plan paid for a limited oral evaluation, bitewing x-rays, and panoramic x-ray that you received on September 30, 2021, thus exhausting the benefits for these services. Additionally, Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), bitewing x-ray (D0270), panoramic x-ray (D0330), and office visit for observation (D9430) provided from October 4, 2021, to October 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on September 24, 2021.  You asked the Plan to waive the copayment for the diagnostic test. You say that the cost-sharing obligation was improperly assessed. The Plan denied your request. The Plan says the provider billed as an outpatient hospital and the proper copayment was applied.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for Diagnostic Procedures/Tests services performed in an Outpatient Hospital. The total amount charged was $241.26 which is less than the copayment amount of $270. Therefore, only $241.26 was charged as the copayment.    You have been asked to pay a $241.26 copayment for the diagnostic test. The diagnostic test falls within the Outpatient diagnostic tests and therapeutic services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided by an out-of-network provider on July 21, 2021.  You asked the Plan to pay for a panoramic radiographic image. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit for D0330 has already 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. The Plan covers one set of panoramic radiographic images every 36 months.  We looked at the file and Medicare rules. Evidence was provided to show that D0330 was provided on January 19, 2021. Based on this information, we decided that the Plan's rules for coverage of a panoramic radiographic image have already been met. Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided by an out-of-network provider on July 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the ultrasound of the head and neck (76536) provided on September 15, 2021.  

You asked the Plan to waive the deductible for the ultrasound. You say that this was a necessary service and you do not understand why it is not being covered. The Plan denied your request. The Plan says this service is covered, and this claim was processed in accordance with your contract. The Plan has applied their allowed amount (reduced rate) to this ultrasound, and you are responsible for this amount because you had not met your deductible at the time of service.  

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 $750 deductible which applies to outpatient radiological diagnostic services.   

The item or service you asked the Plan to waive the deductible for falls within the outpatient radiological diagnostic services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to outpatient radiological diagnostic services. This cost sharing is a contractual obligation that had not been met at the time the ultrasound was received on September 15, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the ultrasound of the head and neck (76536) provided on September 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care (99310) provided on September 13, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the subsequent nursing facility care. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the services were rendered by an OON provider and there is no authorization on file. The Plan also says that there is no referral from an in-network provider for this service.  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 the subsequent nursing facility care (99310) provided on September 13, 2021 by an out-of-network (OON) provider.
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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were evaluated in the Emergency Department on January 27, 2022, and February 6, 2022, for falls and a urinary tract infection and was discharged to the assisted living facility with orders for home health services. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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.