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

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on January 5, 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 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 medical services provided to the enrollee on January 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral lumbar facet joint injections.
You asked the Plan to pre-approve bilateral lumbar facet joint injections. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the coverage criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that in order for subsequent facet joint injections to be covered, the prior injection must have provided at least 80% relief of primary pain. 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 bilateral lumbar facet joint injections. Our reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer found the enrollee is a 69-year-old male with a diagnosis of low back pain secondary to lumbosacral spondylosis, without myelopathy or radiculopathy. He has tried and failed multiple conservative measures including heat, NSAIDS, and physical therapy. The enrollee underwent his first series of therapeutic injections on August 17, 2021, and reported 0% relief from the procedure. As a result, the criteria for coverage have 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 bilateral lumbar facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral lumbar facet joint injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for inpatient hospital care provided from June 4, 2020, through June 5, 2020.
You asked the Plan to waive the deductible for inpatient hospital care. You say that you should not have to pay this charge. The Plan denied your request. The Plan says the cost share was applied 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 $300 deductible for inpatient hospital care. You have been asked to pay a $300 deductible for inpatient hospital care The services at issue fall 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 deductible for inpatient hospital care provided from June 4, 2020, through June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the first intraoral periapical x-ray (D0220), resin-based composite
(D2335), crown (D2740), and core buildup, including any pins when required (D2950) provided on January 13,
2021, by an OON provider.
You asked the Plan to pay for the first intraoral periapical x-ray, resin-based composite, crown, and core
buildup. You say that you were out of state and needed to have an emergency dental procedure. You also say
that you found a dentist that accepted your insurance. The Plan denied your request. The Plan says that services
rendered by a dentist who does not participate with your plan is not a covered benefit under your plan.
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 Plan did not provide a copy of the applicable 2021 Evidence of Coverage or
2021 Summary of Dental Plan Benefits for this case. We asked for these documents, but they were not
provided to us. Without this information we cannot determine that the Plan's coverage rules support the denial
of payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and
benefits. Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we
decided that the Plan has to pay for the first intraoral periapical x-ray (D0220), resin-based composite (D2335),
crown (D2740), and core buildup, including any pins when required (D2950) provided on January 13, 2021, by
an OON provider.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by an out-of-network provider on March 30, 2020.
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for outpatient surgery/out-of-network.
You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery. The total allowed amount is $5,612.88. The total amount you are being asked to pay is $1,122.58 ($5,612.88 x 20% = $1,122.58). An outpatient surgery falls within the outpatient surgery/out-of-network 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 an outpatient surgery provided by an out-of-network provider on March 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive cardiovascular genetic panel (81407,
81408) provided on February 8, 2021.
You asked the Plan to pay for a comprehensive cardiovascular genetic panel. You say that this is supported in
the records. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
(CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients.
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not
covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive
cardiovascular genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a
comprehensive cardiovascular genetic panel (81407, 81408) provided on February 8, 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 this is medically necessary. The Plan denied your
request. The Plan says the services could be safely received in other settings, for example: a skilled nursing
facility, home with home health and home physical therapy.
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. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
surgical management of a radial fracture and non surgical management of lumbar compression fractures after a
motor vehicle accident. 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 the medical record supports a need for physical and/or
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary
care can be provided in a different level of care. 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.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider from January 4, 2021, through January 14, 2021.
You asked the Plan to pay for physical therapy. You say that medical records and all necessary documents are attached along with the letter to consider this claim for payment. You say that the claims should be reprocessed for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not 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 physical therapy provided by an out-of-network provider from January 4, 2021, through January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a foldable electric wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is the only power wheelchair that will fit in your vehicle. The Plan denied your request. The Plan says the requested item is a brand-specific item that is not a Medicare DME supplier.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a foldable electric wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation provided on May 24, 2021.
You asked the Plan to pay for the limited oral evaluation. You say that you went to the dentist because your gums were swollen with small spots of irritation and the pain was unbearable You say that the cleaning appointment should have no bearing on the appointment for your gum problem. The Plan denied your request. The Plan says the service is only covered once per plan year.
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, a limited oral evaluation (D0140) is only covered once per plan year. The Plan paid for a limited oral evaluation provided on May 11, 2021, which exhausted your benefit.
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation provided on May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for several surgical extractions (D7210) and two alveoloplasty procedures (D7310) provided on December 8, 2020.
You asked the Plan to pay for the dental services. You say that you already paid part of the cost for these services on the date they were provided and feel the Plan should cover the bill that was sent to you afterward. The Plan denied your request. The Plan says they have already covered $1,500 for dental services for you in 2020, and you are responsible for the remaining cost.
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 can cover a maximum of $1,500 per year for supplemental preventative and comprehensive dental services each year. You are responsible for any amount over and above the allowance amount. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services that exceed the Plan's maximum annual dental allowance are not covered under this benefit. Documentation shows that the Plan has covered the full $1,500 for dental services for you in 2020. Therefore, we decided that the Plan does not have to pay for several surgical extractions (D7210) and two alveoloplasty procedures (D7310) provided on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out-of-network physician services provided to the enrollee
on September 3, 2020.
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 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 to the
enrollee on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for patient/caregiver education for initiation of
home international normalized ratio (INR) testing.
You asked the Plan to waive the copayment for anticoagulation management services. You say that you have
been billed for INR blood tests and do not believe you should have a copayment as it is only a finger prick and
finished in a few minutes. The Plan denied your request. The Plan says this claim was processed with the
correct copayments applied per the Evidence of Coverage.
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 $50
copayment for services obtained from a specialist or under certain circumstances, treatment by a nurse
practitioner or physician's assistant or other non-physician health care professions in a specialist office.
You have been asked to pay $63.96 ($11.41 + $10.41 + $10.39 + $10.39 + $10.39 + $10.99) for the
anticoagulation management services. Since the allowed amounts on the dates of service were less than the
copay amounts, you are responsible for the lesser amount. The anticoagulation management services fall s
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 patient/caregiver education for initiation of home international
normalized ratio (INR) testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hearing services provided on March 18, 2021.
You asked the Plan to waive the copayment for tympanometry and reflex threshold measurements (92550) and pure tone audiometry (threshold); air and bone (92550). You say that you should only have a specialist copayment. 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 $45 copayment for Hearing Services. You have been asked to pay a $45 copayment for tympanometry and reflex threshold measurements (92550) and pure tone audiometry (threshold); air and bone (92550). Tympanometry and reflex threshold measurements and pure tone fall within the Hearing 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 the hearing services provided on March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve clinical crown lengthening - hard tissue (D4249) for the enrollee.
You asked the Plan to pre-approve the dental services. You say that there is currently not enough tooth
structure above the crest of the bone to prepare a new crown for tooth #29. The Plan denied your request. The
Plan says that the records appear to show evidence of general gum and bone disease.
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 plan's denial reason claims that the dental records do not show evidence of
general gum and bone disease. The plan did not provide these necessary records that were clearly used in their
denial. The plan has not substantiated their denial. Therefore, we decided that the Plan has to pre-approve
clinical crown lengthening - hard tissue (D4249) for the enrollee.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the HHA or CNA (S9122) and non-emergency transportation (T2003) provided from March 1, 2021, to March 15, 2021.
You asked the Plan to pay for the HHA or CNA and non-emergency transportation. The Plan denied your request. The Plan says these services were rendered by a provider who is not under contract with the Plan and has opted out of Medicare, and services that are not covered by the Plan.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. The services were rendered by a non-certified Medicare provider. Based on this information, we decided that Medicare rules for coverage of the HHA or CNA and non-emergency transportation have not been met. Therefore, we decided that the Plan does not have to pay for the HHA or CNA (S9122) and non-emergency transportation (T2003) provided from March 1, 2021, to March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on February 15, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on February 15, 2021.