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

 We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes (97811) provided August 16, 2021.  You asked the Plan to pay for the acupuncture services. You say that you should not be held responsible for these charges since the Plan's website provided misleading information as well as the delay in the clinic in advising you that these service were not covered. The Plan denied your request. The Plan says acupuncture for the treatment of hand pain is not a covered benefit.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.   We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the Plan covers acupuncture only for the treatment of lower back pain. The records show that these services were for the treatment of hand pain. Therefore, we decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes (97811) provided August 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the physical therapy (PT) services (97535, 97161, 97110, 97140) provided on November 4, 2020.  

You asked the Plan to waive the deductible for the PT services. You say that this claim was processed in error, as you had previously satisfied your 2020 deductible for the year. The Plan denied your request. The Plan says this claim was processed correctly, and you had not met your 2020 deductible prior to these therapy services.  

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 $195 deductible which applies to outpatient rehabilitation services.   

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $195 deductible which applies to outpatient rehabilitation services. Documentation supports that you had previously paid $100.86 into your deductible prior to the date in question, and the $94.14 ($100.86 + $94.14 = $195) was applied to the deductible correctly. This cost sharing is a contractual obligation that had not been met at the time the PT services were received on November 4, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the physical therapy (PT) services (97535, 97161, 97110, 97140) provided on November 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the local anesthesia in conjunction with operative or surgical procedures (D9215) provided on August 5, 2021.  You asked the Plan to pay for the dental service. You say that you have had an extraction done previously. You say that you experienced a severe anxiety attack during major dental procedure. You say that you have received nitrous oxide prior to the use of general anesthesia and have not had repeat issues. The Plan denied your request. The Plan says local anesthesia in conjunction with operative or surgical procedures is not listed as a covered 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.  Though the Plan offers a dental benefit in excess of Medicare coverage, the local anesthesia in conjunction with operative or surgical procedures is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the local anesthesia in conjunction with operative or surgical procedures (D9215) provided on August 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve out-of-network physical and occupational therapy  

You asked the Plan to pre-approve out-of-network physical and occupational therapy. You say that you won't need transportation because you can walk right there since it is in your building. The Plan denied your request. The Plan says in-network home health agencies are 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.     

The requested provider in this case is not a network provider with the Plan. The Plan has in- network home health providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve out-of-network physical and occupational therapy
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from March 13, 2021, to March 25, 2021.  

You asked the Plan to waive the copayment for the inpatient care. You say that you were told all copays related to COVID-19 were waived through the end of February, and you would like this copayment to be waived as well because these necessary services were rendered so soon after the waiver ended. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. There was no cost share waiver for inpatient treatment services of COVID-19 in effect at the time of your inpatient stay.    

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 $260 copayment for each of the first five days of an inpatient stay. There is a $0 copayment for additional days.  

You have been asked to pay a $1,300 copayment for an inpatient hospital stay which exceeded five days ($260 x 5 = $1,300). 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 admission and services provided from March 13, 2021, to March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrocentesis.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.

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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the submitted records show that you
had a previous injection for tailbone pain (coccygodynia). You have tried physical therapy and a home exercise
program and take pain relief medications. You had pain relief across a broad area of the back but still had
tailbone pain. Given that you did not receive pain relief from the prior injection, the repeat arthrocentesis is not
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve arthrocentesis.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home health aide (HHA) (G0156).  

You asked the Plan to pre-approve the HHA. The Plan denied your request. The Plan says you no longer qualify for HHA services.  

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.   

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 HHA. Our reviewer says that the HHA services are not medically reasonable and necessary. Our physician reviewer found you do not currently have documented skilled nursing needs. Our reviewer found that you do not currently have documented skilled therapy needs. Our physician reviewer also found that in the absence of the provision of skilled services, associated HHA services are not medically necessary, reasonable, or coverable.     

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 HHA have not been met. Therefore, we decided that the Plan does not have to pre-approve a home health aide (HHA) (G0156).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xiidra drops 5% for the enrollee.  You asked the Plan to pre-approve the drops. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not have pharmacy (drug) benefits administered by the plan.  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 Xiidra drops 5% for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia (J0897).  

You asked the Plan to pre-approve Prolia. You say that the enrollee was on Fosamax for 5 years. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drug, zoledronic acid. 

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria.
  
The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  

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 Prolia. Our reviewer says that the requested drug Prolia is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has not tried and failed the required drug, zoledronic acid. The reviewer also found that the documentation does not support that zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the reviewer found that the requested drug is not medically necessary as the step therapy criteria has not been met. 

 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Specifically, the file shows that the enrollee has not tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen concentrator.  You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says this is going to be used for travel outside of the United States.  The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.    To qualify for home oxygen, the patient must meet one of the following blood gas levels:  1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;  2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;   3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;  4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.  For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage.  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 concentrator. Our reviewer says that the requested concentrator is not medically reasonable or necessary. Our physician reviewer found you have chronic lung disease are on home oxygen. The item is to be used for air travel outside of the U.S. Medicare does not cover this item for air travel, or for use outside of the U.S.  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 concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aids and receivers provided on May 28, 2021.  

You asked the Plan to pay for the hearing aids and receivers. You say that the hearing aids were cheaper and better than the ones from the preferred provider. The Plan denied your request. The Plan says the services were not provided by a preferred provider.  

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are received from the Plan's hearing aid vendor.   

We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids and receivers have not been met. Specifically, the hearing aids were not purchased from the Plan's hearing aid vendor. Therefore, we decided that the Plan does not have to pay for the hearing aids and receivers provided on May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings (D0274), and prophylaxis (D1110) provided by a participating provider on September 15, 2021.  You asked the Plan to pay for a periodic oral evaluation, bitewings, and prophylaxis. You say that you did not know that you had used all the $1,000 coverage limit. The Plan denied your request. The Plan says the benefit limit for dental services was met.  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 preventative dental services up to $1,000.   We looked at the file and Medicare rules. Based on this information, we decided that the benefit limit of $1,000 has already been met.  Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings (D0274), and prophylaxis (D1110) provided by a participating provider on September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and additional periapical x-rays (D0230 x 2) provided on August 24, 2021.  

You asked the Plan to pay for the dental services. You say that you received x-rays the year before and they were covered. You also say that you would not have allowed the x-rays to be done if you had known they would not be covered. The Plan denied your request. The Plan says periapical x-rays are not listed as covered services. The Plan also says there is no record that you contacted the plan prior to the date of service to verify 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 periapical x-rays are not among those covered under this benefit. Additionally, the record shows that the Plan did not pay for the periapical x-rays that you received in 2020 either. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and additional periapical x-rays (D0230 x 2) provided on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an extraction to be provided by an oral surgeon.  

You asked the Plan to pre-approve the extraction. You say that your dentist is not able to extract the tooth and has referred you to an oral surgeon. You also say that you feel this service should be covered by the Plan. The Plan denied your request. The Plan says dental services are only covered when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon are not covered.  

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 covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve an extraction to be provided by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services provided on May 16, 2019 to May 30, 2019, as originally billed.

You asked the Plan to pay for the inpatient care as originally billed. You say these services were billed correctly, and the audit of this claim was performed more than 18 months from the date of original payment. The Plan denied your request. The Plan says that insufficient documentation was provided to support the original diagnosis related group (DRG) as billed.

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. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The record indicates that this claim was originally paid in full in 2019. An audit was performed in June 2021, where the Plan discovered payment amount was made in error and attempted to recoup payment of $811. The audit and the Plan's appeal review cite medical records which were initially submitted with this claim. No medical records of any kind, specifically those reviewed by the auditor, were submitted to us for review. The provider is not responsible for submitting the same records twice, and the Plan has not submitted any evidence to show that the reduction of the DRG and recoupment of payment was appropriate. Therefore, we decided that the Plan has to pay for the inpatient hospital services provided on May 16, 2019 to May 30, 2019, as originally billed.

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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax for the enrollee.  You asked the Plan to pre-approve the scan. You say that this is medically necessary for a diagnosis of pneumoconiosis due to asbestos and mineral fibers. The Plan denied your request. The Plan says no further imaging is supported at this time.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee is a past smoker, having quit in 1965, with 15 pack years of smoking history. Therefore, he would not qualify for annual lung cancer screening. The purpose of this requested scan was to follow-up on apical and pleural scarring, and a 2-3 mm pulmonary nodule, which have been stable since August 2020. The most recent CT scan was in June 2021. The Fleischner Society Guidelines indicate that for a high-risk patient with a nodule less than 6mm, a single 12 month follow-up scan is optional. n this case, the 10 month follow-up is deemed adequate for this purpose. No further CT scans are indicated, in the absence of symptoms or chest x-ray (CXR) abnormalities, given the size of the nodule and the stability of the abnormalities    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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax for the enrollee.