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

 We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).  You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/investigational.  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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the procedure at issue is considered experimental/investigational. Two learned societies have not endorsed the use of this procedure for spinal stenosis.  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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the extractions (D7140 and D7210) provided on January 25, 2021 and January 27, 2021.  

You asked the Plan to pay for the extractions (D7140 and D7210). You say that the dental clinic adjusted payments to make you owe $40 fees. You say that you are disabled, and payment should made. The Plan denied your request. The Plan says extractions are not a covered benefit.  

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 the extractions (D7140 and D7210) provided on January 25, 2021 and January 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve mounting bracket assembly tie downs (K0108) for the enrollee.  You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says this item is for use outside of the home.  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 rules also say that for equipment to be covered, it must serve a primarily medical purpose.  The item at issue in this appeal is for use outside of the home, and does not serve a medical purpose. 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 mounting bracket assembly tie downs (K0108) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for inpatient hospital care provided from February 5, 2021, to March 9, 2021.  You asked the Plan to waive the copayments for inpatient hospital care. You say that you disagree with being charged $250 each time you are admitted to the hospital or inpatient rehabilitation because they are all within the same building. 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 $250 copayment for each hospital stay, including inpatient rehabilitation.  You received inpatient hospital care from February 5, 2021, to March 9, 2021, for a total of 4 inpatient admissions. Therefore, the total amount you owe is: $250 (copayment) x 4 (inpatient hospital admissions) = $1,000.    You have been asked to pay the total copayment amount of $1,000 for inpatient hospital care. Inpatient hospital care 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 copayments for inpatient hospital care provided from February 5, 2021, to March 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bone imaging (78306) with Medronate (A9503).  You asked the Plan to pre-approve bone imaging with Medronate. You say that the requested services are a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the requested services have not been met.  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 bone imaging with Medronate. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.   Our physician reviewer found that you apparently have not yet seen a podiatrist although a referral is planned. You had a bone scan last year but no results are in the provided records. There also is no record of a plain film of the symptomatic foot. Absent these details the medical necessity of the requested bone scan has not been established.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone imaging with Medronate have not been met. Therefore, we decided that the Plan does not have to pre-approve bone imaging (78306) with Medronate (A9503).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on July 12, 2021.  You asked the Plan to waive the copayment for inpatient hospital care. You say that you do not recall having to pay a $300 copayment for inpatient hospital care. 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 $300 copayment each time you are admitted inpatient for inpatient hospital care. You will not pay more than $900 for inpatient hospital care services.  You received inpatient hospital care on July 12, 2021. Therefore, you are responsible to pay the $300 copayment.   You have been asked to pay a $300 copayment for inpatient hospital care. Inpatient hospital care 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 inpatient hospital care provided on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), gingival irrigation (D421 x 4), and take-home drugs (D9630 x 2) provided on August 18, 2021.  You asked the Plan to pay for the dental services. You say that the dentist performed a deep cleaning because your oral health required it. You say that you had an infection below the gum line. You say that only a deep cleaning would get rid of the infection. You also say that the services listed in the denial should be covered. The Plan denied your request. The Plan says adjunctive pre-diagnostic test is not listed as a covered service. The Plan says that gingival irrigation is not listed as a covered service. The Plan also says take home drugs are not listed as covered services either.  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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), gingival irrigation (D421 x 4), and take-home drugs (D9630 x 2) provided on August 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services provided on September 2, 2021.  You asked the Plan to waive the copayment for ambulance services. You say that you did not have a choice on the provider and would not have chosen an out-of-network provider. 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 $290 copayment for in-network and out-of-network ambulance services.  You have been asked to pay the allowed amount of $234.18, which is less than the $290 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on September 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapy services and vitamin injections provided on March 24, 2021.  You asked the Plan to pay for the therapy services and vitamin injections. The Plan denied your request. The Plan says this is not a Medicare covered benefit.    The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. Medicare rules say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapy services and vitamin injections have not been met. Specifically, the physical therapy services at issue in this case were rendered by a nurse practitioner who is not licensed to provide physical therapy.   In addition, the drug code reported on this claim refers to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to pay for the therapy services and vitamin injections provided on March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on August 9, 2021.  You asked the Plan to pay for the re-cement or re-bond crown. You say that this was the cheapest and most efficient way to repair the crown. The Plan denied your request. The Plan says this is not 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on August 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan provided on July 19, 2021.  You asked the Plan to waive the copayment for the CT scan. You say that you are on a fixed income and this will cause you hardship. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for diagnostic radiology services that are not ultrasounds.   You have been asked to pay $207.19, which is less than the $325 copayment for the CT scan. CT scans fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan provided on July 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the urinalysis provided on August 12, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the urinalysis. You say that the enrollee was seen by an in-network physician with no control over which laboratory was used. The Plan denied your request. The Plan says no prior authorization was obtained.  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. The record shows the referring provider was out-of-network. Therefore, we decided that the Plan does not have to pay for the urinalysis provided on August 12, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided on August 2, 2021.  You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you were told that the test would only cost $100 and you disagree with the additional $4 charge. 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 20% coinsurance for Medicare Part B prescription drugs.   You received a Medicare Part B drug injection on August 2, 2021. The total allowed amount is $20 and 20% of that is $4.   You have been asked to pay the total coinsurance amount of $4 for a Medicare Part B drug injection. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 a Medicare Part B drug injection provided on August 2, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pre-approve an oral and maxillofacial surgery consult with an out of network provider.  You asked the Plan to pre-approve the consult with an out of network provider. You say that you do not want to see the in network oral surgeon that you were referred to. You say that the in network oral surgeon is 4 hours away from you. The Plan denied your request. The Plan says that the requested service can be provided in network.  Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The Plan says that enrollees must use contract providers.   The requested provider is a non-contract provider. The recommended in network provider is not located within reasonable distance and travel time from your home who can provide the consult with an out of network provider. Under Medicare rules, this means that contract providers are not accessible to you. Therefore, we decided that the Plan has to pre-approve an oral and maxillofacial surgery consult with an out of network 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 pay for the office visit provided on December 10, 2020, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  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. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for an office visit provided on December 10, 2020, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on June 8, 2020.  You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 pay for ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found that the enrollee was discharged from the hospital for altered mental status and dementia and was transported via ambulance to an assisted living facility. The enrollee's vitals were normal, he was confused but cooperative and alert and in no distress. He ambulated to the stretcher with assistance. The enrollee was not treated during transport and there were no reported complications. The documentation does not support that other means of transport such as stretcher van were contraindicated. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The documentation does not support that the ambulance transport was medically reasonable and necessary for the patient.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on June 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the bitewing x-rays (D0274) provided on June 1, 2021.  You asked the Plan to reimburse you for the bitewing x-rays. You say that the services you received should be covered. The Plan denied your request. The Plan says bitewing x-rays are covered once per calendar year. The Plan also says that the frequency limit has been exceeded.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the bitewing x-rays have not been met. Specifically, the frequency limit has been exceeded. The record shows that the Plan paid for bitewing x-rays that you received on September 3, 2021. Therefore, we decided that the Plan does not have to reimburse you for the bitewing x-rays (D0274) provided on June 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a knee orthosis (L1851).  You asked the Plan to pre-approve a knee orthosis. You say that this device is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that the requested knee orthosis is subject to the criteria listed 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 a knee orthosis. Our reviewer says that the requested knee orthosis is not medically reasonable and necessary. Our physician reviewer found that the record indicates that the enrollee has osteoarthritis of the knee. The record does not indicate that the enrollee has had a recent injury to or a surgical procedure. The record does not provide physical examination documentation of knee instability. The elements of the coverage criteria are not satisfied.  The requested service is not recommended.  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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1851).