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

We decided that the Plan does not have to pay for an x-ray provided on March 17, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for an x-ray. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 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 an x-ray provided on March 17, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to reimburse for the total difference between your cost-share and the supplier's
bill for the ostomy supplies. We decided that the Plan does not have to waive the 20% of the total supplier bill
for the ostomy supplies.

You asked the Plan to waive the cost-share for the ostomy supplies. You say that you purchased the ostomy
supplies like you have done every year. You state this is covered by your policy at 80%. You state you paid the
full amount to the provider. The Plan states they had a conversation with on June 30, 2021, about the
reimbursements sent, and how the Health Plan reimbursed you based on Medicare allowed amounts. The Plan
states, unfortunately the provider for these claims: The provider does NOT accept Medicare assignment, and is
not in network for your Health Plan. The Plan states if a provider does NOT accept Medicare assignment, they
do not have to abide by the amounts that Medicare allows for a service.

We decided that the Plan has to reimburse for the total difference between your cost-share and the
supplier's bill for the ostomy supplies.

The rules say that for an MA-plan, non-contracting, non-participating DME supplier, the MAO must pay the
non-contracting non-participating (non-par) DME supplier the difference between the enrollee's cost-sharing
and the DME supplier's bill; the enrollee only pays plan-allowed cost-sharing. The coinsurance percentage is
multiplied by the total provider bill, if the MAO uses a coinsurance method for its cost-sharing. Note that the
total provider bill may include permitted balance billing. Therefore, we decided that the Plan has reimburse for
the total difference between your cost-share and the supplier's bill for the ostomy supplies.

We also decided that the Plan does not have to waive the 20% of the total supplier bill for the ostomy
supplies.

Review of the file show that you purchased the ostomy supplies from January 3, 2020, through November 30,
2020. You were asked to pay 20% of the total cost of Medicare-covered medical supplies. Therefore, we
decided that the Plan does not have to waive 20% of the total supplier bill for the ostomy supplies.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan
denied your request. The Plan says the plan only offers a certain number of trips per year.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 24 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
You asked the Plan to pre-approve the dental item. You say that you wrapped your bottom dentures in a napkin. You also say that you accidentally threw them out. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit has been reached.
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 and dentures are listed as covered, the frequency limit has been reached. The record shows that the Plan paid for dentures that you received on February 22, 2021. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110), reline of a
complete maxillary denture (D5750), and maxillary tissue conditioning (D5850).
You asked the Plan to pre-approve the complete maxillary denture, reline of a complete maxillary denture, and
maxillary tissue conditioning. You say that it is important for your oral health to get dentures. You also say that
if you cannot get the dentures you will not have a lot of teeth on the top of your mouth which will affect your
ability to eat. The Plan denied your request. The Plan says these services are not covered under your benefit
package.
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 a
complete maxillary denture (D5110), reline of a complete maxillary denture (D5750), and maxillary tissue
conditioning (D5850).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for a power
wheelchair.

You asked the Plan to pre-approve a power seat elevation system. You say that the requested feature is a
medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met
because the requested item does not serve a medical purpose.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we
decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for a power
wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient mental health services
provided from April 14, 2021, to May 7, 2021.

You asked the Plan to waive the copayment for the inpatient mental health services. You say that the enrollee's
stay was longer than anticipated due to her hone situation and lack of community supports. The Plan denied
your request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $95 copayment for days 1-10 and $0 per day for days 11-90 for inpatient mental health care.

Records show that the enrollee received inpatient mental health care for a total of 24 days. The enrollee has
been asked to pay a $95 copayment for days 1-10, for a total of $950. As per the contract, she was not charged
additional cost sharing for days 11-24. This copayment applies regardless of the reason for the length of the
stay. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan.
This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore,
we decided that the Plan does not have to waive the copayment for the inpatient mental health services
provided from April 14, 2021, to May 7, 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 the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.
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 based on the medical records provided the complexity of the enrollee's nursing,
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an
IRF level of care.
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 pay more toward the dental services provided by an opt out provider on April 7, 2021.

You asked the Plan to pay more toward the dental services. You say that you should have received more reimbursement. The Plan denied your request. The Plan says payment cannot be issued for services performed by a provider that has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay more toward the dental services provided by an opt out provider on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on March 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
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 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 physician services provided on March 5, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2740), core buildup (D2950), pontics
(D6245), periodontal scaling and root planing (D4341) and abutment supported crown (D6058) for tooth #17.

You asked the Plan to pre-approve the crowns (D2740), core buildup (D2950), pontics (D6245), periodontal
scaling and root planing (D4341) and abutment supported crown (D6058). The Plan denied your request. The
Plan says the crowns (D2740), core buildup (D2950), pontics (D6245) are not covered benefits. Periodontal
scaling and root planing (D4341) is only covered once every three years and an abutment supported crown
(D6058) is not covered for the requested tooth.

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 crowns (D2740), core buildup
(D2950) and pontics (D6245) are not among those covered under this benefit. Periodontal scaling and root
planing is only covered once every three years. The Plan paid for periodontal scaling and root planing in all
quadrants provided on February 4, 2021, which exhausted the benefit. An abutment supported crown (D6058)
is only covered for tooth #'s 2-15 and 18-31. Therefore, we decided that the Plan does not have to pre-approve
crowns (D2740), core buildup (D2950), pontics (D6245), periodontal scaling and root planing (D4341) and
abutment supported crown (D6058) for tooth #17.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral to a dermatologist.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has 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 an out-of-network referral to a dermatologist.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) additional outpatient physical therapy visits.

You asked the Plan to pre-approve the visits. You say that this is medically necessary based on pain in your right lower leg. The Plan denied your request. The Plan says you are stable to continue rehabilitation with the home exercise program and follow-up with your physician. The Plan states that it appears that your current formal therapy should meet clinical expectations with the now total twenty-four (24) approved visits. The Plan states there is nothing in the supplied documentation that supports that the services will be of such a level of complexity and sophistication, or your condition will be such that the services required can be safely and effectively performed only by a qualified therapist or under a therapist's supervision, versus a home exercise program after the total approved visits.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. You should be able to transition to an independent home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twelve (12) additional outpatient physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a rhinoplasty surgery to be provided by an OON
provider.
You asked the Plan to pre-approve a rhinoplasty surgery. You say that you would like the Plan to approve this
surgery. The Plan denied your request. The Plan says there are in-network providers available for these
services.
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 rhinoplasty surgery to be provided by an OON provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided on April 12, 2021, by an
OON provider.

You asked the Plan to pay for pain management services. You say that you would like this claim reprocessed
and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's
primary care physician. The Plan says that there are in-network providers available for these services.

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 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 pain management services provided on April 12,
2021, by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the hot or cold packs therapy provided on April 26, 2021.
You asked the Plan to pay for the hot or cold packs therapy. You say that authorization is not needed, and the
claim should be reprocessed. The Plan denied your request. The Plan says CPT code 97010 is not eligible for
separate reimbursement.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 97010 is application of a modality to 1 or more areas; hot
or cold packs.
We find that CPT code 97010 is not supported in the medical record. Specifically, CPT code 97010 has a status indicator of B. This means that CPT code 97010 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have to pay for the hot or cold packs therapy provided on April 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on April 29, 2021.

You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you have never had to pay more than the $25 copayment and disagree with the charges. You state that you were told your benefits had not changed but now you are being charged for your injections. 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 Medicare Part B drugs on April 29, 2021. The total allowed amount is $3,430.70 and 20% of that is $686.14. 

You have been asked to pay the total coinsurance amount of $686.14 for Medicare Part B drugs. Medicare Part B drugs fall 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 Medicare Part B drugs provided on April 29, 2021.