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

 We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) rendered by the out-of-network (OON) provider on May 13, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) rendered by the out-of-network (OON) provider on May 13, 2021.
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 you are waiting in the hospital to be released to LTACH and cannot be discharged to go home. The Plan denied your request. The Plan says you are receiving appropriate in-patient acute care and are currently unstable for transfer to an LTACH.  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 that there is no documentation provided indicating medical necessity for LTACH services. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis.  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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve four osseous, osteoperiosteal, or cartilage grafts of the mandible (D7950 x4).  You asked the Plan to pre-approve the osseous, osteoperiosteal, or cartilage grafts. The Plan denied your request. The Plan says this service is not listed as 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 pre-approve four osseous, osteoperiosteal, or cartilage grafts of the mandible (D7950 x4).
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) for tooth #18.  You asked the Plan to pre-approve a bone replacement graft. You say that this service is necessary to prevent possible infection. The Plan denied your request. The Plan says this service is not covered by your dental 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 pre-approve a bone replacement graft for ridge preservation (D7953) for tooth #18.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on August 12, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that you needed treatment on the upper left side of your mouth that had become sensitive to hot liquids. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.  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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on May 6, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on August 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a hospital bed and mattress (E0277, E0260).  You asked the Plan to pre-approve a hospital bed and mattress. You say that the facility the enrollee resides in does not have a hospital bed. The Plan denied your request. The Plan says this is not covered.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.   Records show that a hospital bed and mattress are being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a hospital bed and mattress (E0277, E0260).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the crown - porcelain/ceramic (D2740) provided June 10, 2021, and the intraoral - periapical first radiographic image (D0220) and limited oral evaluation - problem focused (D0140) provided July 15, 2021.  You asked the Plan to provide additional payment for the crown, intraoral x-ray and limited oral exam. You say that you feel you are due additional reimbursement for the services. The Plan denied your request. The Plan says the claims have been processed correctly. Additionally, the Plan says they have contacted the provider who has stated that they are processing the requested refund for overpayment made to the provider for the crown.  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 crown and intraoral x-ray once per calendar year.  We looked at the file and Medicare rules. The Plan provided documentation showing that the Plan has processed the claim for the crown with 70% coinsurance. Based on this information, we decided that the Plan does not have to provide additional reimbursement for the crown. The Plan also provided documentation showing that intraoral x-rays were previously covered on December 8, 2020. This means that you have exceeded the frequency limit for intraoral x-rays. Though the Plan offers dental benefits in excess of Medicare coverage, the limited oral exam is not among those covered services. Therefore, we decided that the Plan does not have to provide additional payment for the crown - porcelain/ceramic (D2740) provided June 10, 2021, and the intraoral - periapical first radiographic image (D0220) and limited oral evaluation - problem focused (D0140) provided July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office visit, a cystoscopy, a cytourethroscopy with biopsy, and transurethral surgery procedure on bladder to be provided by the requested out-of-network provider.  You asked the Plan to pre-approve an office visit, a cystoscopy, a cytourethroscopy with biopsy, and transurethral surgery procedure on bladder to be provided by the requested out-of-network provider. You say that your son and a friend work at this medical center, and you would like to receive care there. The Plan denied your request. The Plan says that the Plan will only cover non-contracted providers if the service is for an emergency and if it is medically necessary to go out of network. No information was presented to indicate that this is for emergency care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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, a cystoscopy, a cytourethroscopy with biopsy, and transurethral surgery procedure on bladder to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an electrical bone growth stimulator.  You asked the Plan to pre-approve an electrical bone growth stimulator. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for the requested item have not been met.  The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days.  In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had ceased. Therefore, we decided that the Plan does not have to pre-approve an electrical bone growth stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endodontic therapy (D3320, D3310) for four teeth.  You asked the Plan to pre-approve endodontic therapy. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered by the Plan's dental 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. Endodontics are not covered.  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 endodontic therapy (D3320, D3310) for four teeth.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on April 16, 2021.  You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were asked if you wanted to go to the hospital and were told it would be left up to you. You also say that you thought they did not see it as an emergency, so you did not think you needed to be transported to the emergency room. The Plan denied your request. The Plan says Medicare does not cover ambulance services in cases of non-transport.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on April 16, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on April 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a Hereditary Assessment for Cardiac Conditions provided to the enrollee on February 9, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the clinical value and effectiveness of this testing in the screening of an asymptomatic individual has not been demonstrated in the peer-reviewed literature.  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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee had hypertension and hypercholesterolemia.   The case file does not include medical records from the ordering physician to establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for a Hereditary Assessment for Cardiac Conditions provided to the enrollee on February 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.  You asked the Plan to pre-approve compression stockings. You say that the requested items are a necessity for your care. The Plan denied your request. The Plan says the requested items are not a covered benefit.  The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing.   Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve wound care services (11042) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the wound care services. You say that the services are medically necessary. The Plan denied your request. The Plan says there are network providers available that can provide the services at issue.  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 wound care services (11042) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a vision exam and pay for an eye refraction provided on August 20, 2020.  You asked the Plan to waive the copayment for a vision exam and pay for an eye refraction. The Plan denied your request. The Plan says the claim processed with the correct copayment for the vision exam and an eye refraction is not a covered benefit.  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 $30 copayment for all other Medicare-covered vision services.  The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.  You have been asked to pay a $30 copayment for a vision exam. The vision exam falls within the Vision 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 a vision exam provided on August 20, 2020.    We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the surgical implant placement (D6013).  You asked the Plan to pre-approve the surgical implant placement (D6013). You say that every time you eat your teeth are getting out and you cannot eat well. You say that these implants are anchor points, and you need this procedure done. The Plan denied your request. The Plan says the service is 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 pre-approve the surgical implant placement (D6013).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve eligibility for the Special Supplemental Benefits for the Chronically Ill (SSBCI) benefit.  You asked the Plan to pre-approve SSBCI benefit. You say that you do not agree with the denial. The Plan denied your request. The Plan says you do not meet the criteria established to receive the Special Supplemental Benefit for the Chronically Ill for 2021.  The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SSBCI benefit have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve eligibility for the Special Supplemental Benefits for the Chronically Ill (SSBCI) benefit.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on July 22, 2021.  You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were bitten by an animal and the ambulance referred you to the hospital. You also say that the paramedics did nothing to treat your hand. The Plan denied your request. The Plan says the service in question is not covered under Medicare or your contract under any normal circumstances. The Plan also says that the ambulance benefit is a transport benefit, and if there is no transport, then there is no Medicare-covered service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on July 22, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on July 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for inpatient hospital care and outpatient hospital observation provided from April 19, 2021, to May 14, 2021.  You asked the Plan to waive the copayments for inpatient hospital care and outpatient hospital observation. You say that the services were due to an emergency and were not planned. 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 days 1-6 for inpatient hospital care.  Your contract with the Plan also clearly says that you must pay a $175 copayment for outpatient hospital observation.   You received inpatient hospital care from April 19, 2021, to April 24, 2021. Therefore, you are responsible to pay a $250 copayment for days 1-5 (April 19, 2021, to April 23, 2021). The total amount you owe is: $250 (copayment) x 5 (inpatient days) = $1,250.   You received outpatient hospital observation from May 13, 2021, to May 14, 2021. Therefore, you are responsible to pay the $175 copayment.   The total amount you owe is: $1,425.   You have been asked to pay the total copayment amount of $1,425 for inpatient hospital care and outpatient hospital observation. Inpatient hospital care falls within the inpatient hospital care benefit category. Outpatient hospital observation falls within the outpatient hospital observation 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 and outpatient hospital observation provided from April 19, 2021, to May 14, 2021.