Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 5, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

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 test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on April 19, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with an inappropriate diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Specifically, the record shows that the claim was billed with only one diagnosis code, D63.1. This code has a code first note, which means it is a manifestation code and must be sequenced after an etiology code. Therefore, we decided that the Plan does not have to pay for the services provided on April 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive periodontal evaluation - new or established patient (D0180), osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant (D4260), and bone replacement graft - retained natural tooth - first site in quadrant (D4263) provided February 23, 2021.

You asked the Plan to pay for the comprehensive periodontal exam, osseous surgery and bone replacement graft. You say that when you see an out-of-network doctor it usually costs a little more, but the insurance does pay something, but never nothing. The Plan denied your request. The Plan says these services are not covered under your benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for comprehensive periodontal evaluation - new or established patient (D0180), osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant (D4260), and bone replacement graft - retained natural tooth - first site in quadrant (D4263) provided February 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for laser eye surgeries you had on April 21, 2021, and May 17, 2021, at an ambulatory surgery center.

You asked the Plan to waive the copayments for the laser eye surgeries. You say that earlier this year you had cataract surgery and were only charged one copayment for both eyes. You say you should only have one copayment for both eyes for the laser surgeries as well. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that because the allowed amount for these surgeries ($268.50) is less than your copayment obligation, you are responsible for the full allowed amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for surgery and procedures at an ambulatory surgery center.

You have been asked to pay a $300 copayment for each of the laser surgeries. You had two separate surgeries on different dates, so two copayments applied correctly. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for laser eye surgeries you had on April 21, 2021, and May 17, 2021, at an ambulatory surgery center.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON services. You say that the enrollee's disease is progressing. The Plan denied your request. The Plan says the service is available by a provider within the enrollee's 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 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 network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (PILD).

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 covered.

The Plan must follow Medicare rules. Medicare rules say that PILD is covered for enrollees with lumbar spinal stenosis enrolled in an approved CED trial. 

We looked at the file and Medicare rules. The file shows that the services are not for an approved CED trial. 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 percutaneous image-guided lumbar decompression (PILD).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).

You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. The Plan denied your request. The Plan says these services exceed the maximum counts allowed per period.

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, complete maxillary denture (D5110) and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) and complete mandibular denture (D5120) on August 14, 2019 and your complete maxillary denture (D5110) and complete mandibular denture (D5120) benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical extraction (D7210), removal of an impacted tooth, completely bony, (D7240), a bone replacement graft (D7953), nitrous oxide (D9230) to be provided by an out of network dentist.

You asked the Plan to pre-approve the dental services. You say that you need to see an oral surgeon. You say that this was the only provider that your dentist recommended. You also say that you have tried calling other providers you were given but none of them accept your insurance. The Plan denied your request. The Plan says dental services that you received out of network are not covered. The Plan also says there are in network providers available.

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, dental services that you receive out of network are not among those covered under this benefit. Additionally, the Plan confirmed that there are in network providers available. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction (D7210), removal of an impacted tooth, completely bony, (D7240), a bone replacement graft (D7953), nitrous oxide (D9230) to be provided by an out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you $66.20 for the 2020 weight management program benefit provided on September 27, 2020.

You asked the Plan to reimburse you for the weight management program benefit. You say that the glue fell off the stamp and was returned to you and you sent it back out before the deadline and you believe you should be reimbursed as it was not your fault for mail situation. The Plan denied your request. The Plan says the remaining amount of $66.20 is denied as no proof of payment for that amount was submitted.

The Plan contract says the Plan will reimburse members up to an annual maximum of $150 towards program fees for weight loss programs. Reimbursement requests must be received by the Plan by no later than March 31st of the following year.

We looked at the file and Medicare rules. The file shows that the Plan did not receive proof of payment for the $66.20 amount that was submitted. Based on this information, we decided that Medicare rules for coverage of the weight management program benefit have not been met. Therefore, we decided that the Plan does not have to reimburse you $66.20 for the 2020 weight management program benefit provided on September 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three visits and treatment to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the OON gastroenterology visits and treatment. You say that the enrollee has an ongoing gastrointestinal bleed which has resulted in severe anemia and several blood transfusions. The enrollee has been referred because network specialists are not able to perform the procedure that is needed. The Plan denied your request. The Plan says they have network gastroenterology physicians that specialize in the type of procedures being requested. The Plan says that there is not a network deficiency.

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 network 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 three visits and treatment to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the information submitted does not meet the plan's medical necessity guidelines for coverage.

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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial of Orthovisc and Monovisc before approving Euflexxa. In this case, there is no trial and failure of these drugs. There is no documentation provided indicating that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
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 without rehabilitation the enrollee's quality of life will decline. The enrollee requires occupational and physical therapy. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services do not meet the requirements for approval.

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 that 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from March 29, 2021, to April 6, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were told that you would not owe anything for the inpatient hospital stay while you waited to transfer to a skilled nursing facility. 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 $330 copayment for days 1-6 for inpatient hospital care. 

You had an inpatient hospital stay from March 29, 2021, to April 6, 2021. Therefore, you are responsible to pay a $330 copayment for days 1-6 (March 29, 2021, to April 3, 2021). $330 (copayment) x 6 (inpatient days) = $1,980.00. 

You have been asked to pay the total copayment amount of $1,980.00 for an inpatient hospital stay. An inpatient hospital stay 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 an inpatient hospital stay provided from March 29, 2021, to April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473 x 2).

You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan denied your request. The Plan says removal of torus mandibularis 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 requested removal of torus mandibularis are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473 x 2).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device (22869).

You asked the Plan to pre-approve a Vertiflex device. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is 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 a Vertiflex device. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the vertiflex device is experimental and more research is needed to show safety and efficacy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met. Specifically, experimental items are not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device (22869).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 21 hours of personal care services.

You asked the Plan to pre-approve the additional 21 hours of personal care services. You say that 13 hours per week of personal care services is not enough to take care of the enrollee's needs. The Plan denied your request. The Plan says the assessment does not support the additional 21 hours weekly that is being requested to manage the enrollee's activities of daily living.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional 21 hours of personal care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve an additional 21 hours of personal care services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) and intraoral - periapical each additional radiographic image (D0230) provided February 23, 2021.

You asked the Plan to pay for the dental consultation and intraoral x-ray. You say that the services were necessary and should be covered. The Plan denied your request. The Plan says there is no coverage for dental consultations and the enrollee has exceeded frequency limits for intraoral x-rays.

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 intraoral x-rays once per calendar year.

We looked at the file, and Medicare rules. The Plan provided documentation showing that intraoral x-rays were previously covered on January 13, 2021. Based on this information, we determined that the Plan's frequency limit for coverage of the intraoral x-rays has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, dental consultations are not among those service covered. Therefore, we decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) and intraoral - periapical each additional radiographic image (D0230) provided February 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional home health skilled nursing visits (G0299).

You asked the Plan to pre-approve 5 additional home health skilled nursing visits. You say that this request is medically necessary. The Plan denied your request. The Plan says these additional home health visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 5 additional home health skilled nursing visits. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found that in this case, the documentation does not support that the member requires additional skilled nursing services to provide treatment that is medically necessary. The member does not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The approved home health visits should be sufficient to educate the member regarding her medical condition. The requested home health services are 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 5 additional home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 additional home health skilled nursing visits (G0299).