Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmental pneumatic appliance and pneumatic compressor to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a segmental pneumatic appliance and pneumatic compressor. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items can be provided by a network provider.
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 a segmental pneumatic appliance and pneumatic compressor to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the positron emission tomography (PET)
scan you had on February 26, 2020.
You asked the Plan to waive the copayment for the PET scan. You say that you were told there would be no
cost share for this service. 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 $250
copayment for diagnostic radiology services.
You have been asked to pay a $250 copayment for the PET scan. The PET scan falls within the diagnostic
radiology 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 positron emission
tomography (PET) scan you had on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an eye exam provided on April 26, 2021.
You asked the Plan to waive the deductible for an eye exam. You say that you disagree with the charges
because your benefits say that you owe a $0 copayment for routine eye exams. 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. Your
contract with the Plan says that there is a $500 deductible which applies to vision care.
The record shows that you received vision care on April 26, 2021, that went beyond a glaucoma screening or
diabetic screening. Therefore, you are responsible to pay your share of the cost-sharing charges. The record
shows that you had only paid $261.75 toward the $500 deductible prior to receiving the services. Therefore,
you are responsible to pay the allowed amount of $117.84.
The item or service you asked the Plan to waive the deductible for falls within the benefit category vision care.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which
applies to vision care. This cost sharing is a contractual obligation that had not been met at the time an eye
exam was received on April 26, 2021. Therefore, we decided that the Plan does not have to waive the
deductible for an eye exam provided on April 26, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs and administration
you received on August 4, 2021.
You asked the Plan to waive the coinsurance for the chemotherapy drugs and administration. You say that you
were told that your copayment would only be $90. The Plan denied your request. The Plan says you were
charged this coinsurance 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 20%
coinsurance for chemotherapy drugs and administration.
You have been asked to pay 20% coinsurance for the chemotherapy drugs and administration. 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 chemotherapy drugs and administration you received on August 4,
2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) receiver (K0554) and supplies (K0553), provided on April 1, 2021.

You asked the Plan to pay for the CGM and supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says the enrollee does not test blood glucose levels at least four times a day.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) receiver (K0554) and supplies (K0553), provided on April 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had at an outpatient hospital facility on July 29, 2021.

You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you were in a life-or-death situation and needed a colonoscopy. You stated that you had diverticulitis and a blockage in your colon. You said that you were led to believe this this was covered in full and, if anything, the copayment would only be $100. In addition, you stated that this copayment is too high for your limited income. 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 $350 copayment for outpatient surgery and services at an outpatient hospital facility.

You have been asked to pay a $350 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the outpatient surgery and services at an outpatient hospital facility 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 diagnostic colonoscopy you had at an outpatient hospital facility on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the primary care visit you had on August
13, 2020.
You asked the Plan to waive the copayment for the primary care visit. You say that nothing was done except
your preventive visit, so there should be no copayment. The Plan denied your request. The Plan says you were
treated for an existing medical condition during the visit, so the copayment applies.
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 primary care visits.
You have been asked to pay a $20 copayment for the primary care visit. According to the billing records, your
doctor evaluated you for benign prostatic hyperplasia and impaired fasting glucose. The doctor indicated in the
billing that these services were above and beyond what is normally reviewed during a preventive visit. That is
why you were charged this copayment. 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 primary
care visit you had on August 13, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve reinstatement of the OTC benefits.
You asked the Plan to pre-approve reinstatement of the OTC benefits. The Plan denied your request. The Plan says your contract with the Plan clearly states that the OTC benefit does not roll over.
The Plan contract offers a supplemental Over the Counter (OTC) benefit. The OTC benefit amount does not roll over. We looked at the file and the Plan's rules. The file shows that the OTC benefit amount does not roll over. Therefore, we decided that the Plan does not have to pre-approve reinstatement of the OTC benefits you did not used from January 2021, through September 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on July 27, 2021.
You asked the Plan to waive the deductible for an office visit. You say that you disagree with the out-of-
network charges. 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. Your
contract with the Plan says that there is a $750 deductible which applies to out-of-network
physician/practitioner services, including doctor's office visits.
You had an office visit on July 27, 2021, with an out-of-network provider. Therefore, you are responsible to
pay your share of the out-of-network cost-sharing charges. The record shows that you had paid $0 toward the
$750 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of
$126.50.
The item or service you asked the Plan to waive the deductible for falls within the benefit category
physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $750 deductible which applies to out-of-network physician/practitioner
services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at
the time an office visit was received on July 27, 2021. Therefore, we decided that the Plan does not have to
waive the deductible for an office visit provided on July 27, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation (D7953), biologic materials to aid in soft and osseous tissue regeneration (D4265), guided tissue regeneration (D4266), cone beam computed tomography (CT) capture and interpretation (D0367), and implant placement (D6010).
You asked the Plan to pre-approve the dental services. You say that the enrollee has been paying for extra coverage through the dental rider for the last 2 years. You say that the enrollee has not used the coverage for
almost 2 years due to the pandemic. You also say that the enrollee needs these services. The Plan denied your request. The Plan says the requested dental services are not listed as 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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation (D7953), biologic materials to aid in soft and osseous tissue regeneration (D4265), guided tissue regeneration (D4266), cone beam computed tomography (CT) capture and interpretation (D0367), and implant placement (D6010).
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 he requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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.  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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286), removal of an impacted tooth (D7241), a coronectomy (D7251), and a bone replacement graft (D7953) provided by a participating provider.
You asked the Plan to pre-approve an incisional biopsy of oral tissue, removal of an impacted tooth, a coronectomy, and a bone replacement graft. You say that you would like approval for these services to be provided. The Plan denied your request. The Plan says the requested dental services are not covered 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 pre-approve an
incisional biopsy of oral tissue (D7286), removal of an impacted tooth (D7241), a coronectomy (D7251), and a bone replacement graft (D7953) provided by a participating provider
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Intracept procedure.  You asked the Plan to pre-approve Intracept procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 Intracept procedure. 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 longstanding back pain. The Intracept procedure is experimental. 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where he/she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.   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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675).  You asked the Plan to pay for a pneumatic compression device. You say that this item should be covered. The Plan denied your request. The Plan says this device is not covered when used during or after surgery.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the two resin-based composites of two surfaces (D2331 x2) provided on July 29, 2021.  You asked the Plan to pay more for the resin-based composites. You say that the Plan needs to pay the full amount for these charges. The Plan denied your request. The Plan says the claim should pay at the original code and you are not responsible for the difference in payment of the procedure codes. The Plan also says that you are only responsible for the 20% copayment for the original code D2331.  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, you are responsible for a 20% coinsurance for Class 2 Basic Services, including white fillings. Therefore, we decided that the Plan does not have to pay more for the two resin-based composites of two surfaces (D2331 x2) provided on July 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight manual wheelchair.

You asked the Plan to pre-approve the requested wheelchair. The Plan denied your request. The Plan says coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that manual wheelchairs are only covered under certain medical indications. 

We looked at the file and Medicare rules. The records provided do not indicate the enrollee meets the weight capacity for the requested wheelchair. The records do not show the enrollee is unable to self-propel a standard wheelchair. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a lightweight manual wheelchair.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on June 19, 2021.  You asked the Plan to pay for the CT scan. You say that the records show the service was medically necessary. The Plan denied your request. The Plan says the scan was reported with a diagnosis that is not covered.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.   We looked at the file, and Medicare rules. In this case, there are insufficient records to show that the results of the testing will impact clinical management in a manner already demonstrated in the peer-reviewed published literature to improve the enrollee's outcome. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on June 19, 2021.