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

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on April 29, 2021, to May 13, 2021.
You asked the Plan to waive the coinsurance for an injection. You say that you were never told that your cost would be this much. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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% coinsurance for Medicare Part B prescription drugs. You have been asked to pay less than a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $36,511.60. The 20% coinsurance is $7,302.32 ($36,511.60 x 20% = $7,302.32). You are being asked to pay $5,755.20, which is less than your 20% coinsurance. An 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 an injection provided by a participating provider on April 29, 2021, to May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on April 14, 2021.
You asked the Plan to pay for the dental services. You say that you have met your out-of-pocket cost. The Plan
denied your request. The Plan says the services 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.
The file shows that a cone beam computed tomography (CT) scan and radiographic implant index were
provided. Although the Plan offers a dental benefit in excess of Medicare coverage, these services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental
services provided on April 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.
You asked the Plan to pay for the LTACH services. You say that transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving the appropriate inpatient acute care at the current facility and these medically necessary services will continued to be covered by the Plan until transfer to a lower level of care becomes appropriate or until the clinical circumstances change such that an LTACH may be reconsidered.
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 pay for 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 in this case, the enrollee is not considered clinically stable. The enrollee is receiving continued acute care services, and these have not been denied by the Plan. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied; the requested service cannot be 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pay for long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
and supplies. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a CPAP device is covered when specific criteria 
are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is said to have chronic 
obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), and obesity hypoventilation syndrome 
(OHS) but the records do not include data to support these diagnoses, such as pulmonary function tests, sleep 
study results, or an arterial blood gas study showing carbon dioxide retention when awake and stable. The 
criteria for coverage are not met; therefore, the the services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous positive airway pressure (CPAP) device and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth #19 and 21.
You asked the Plan to pre-approve the retainer crowns. You say that the enrollee's bridge is broken. You say
that the enrollee states they are suffering and cannot eat well without the bridge. You also say that the enrollee
states that the bridge never fit well, and she was not able to eat. The Plan denied your request. The Plan says
retainer crowns are covered once per tooth every 5 plan 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 retainer crowns are listed as
covered, the frequency limit has been reached. The record shows that the Plan paid for retainer crowns for teeth
#19 and 21 that you received on May 17, 2018. Therefore, we decided that the Plan does not have to preapprove
retainer crowns (D6740) for teeth #19 and 21.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services rendered on March 22, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 11042 is not supported.
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 11042 is debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less. We find that CPT code 11042 is not supported in the medical record. Specifically, there is no documentation of the depth of the wound at issue. Based on this information, we decided that Medicare rules for coverage of
these services have not been met. Therefore, we decided that the Plan does not have to pay for the debridement services rendered on March 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crutch substitute (E0118).
You asked the Plan to pre-approve a crutch substitute. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says there is insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for these products.
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 crutch substitute. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 76-year-old female who is post-surgery and would be comfortable using the requested equipment than standard crutches. The documentation does not reveal that the patient is unable to use crutches post-surgery or that the patient can safely use the requested device. The request exceeds the patient's medical needs. 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 crutch substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute (E0118).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas services rendered from January 28, 2021 to
February 9, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the Sanexas services rendered from January 28, 2021 to February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210), prophylaxis - adult (D1110), and topical application of fluoride - excluding varnish (D1208) provided 
March 3, 2021. 
 
You asked the Plan to pay for the intraoral x-rays, dental cleaning and fluoride treatment. You say that services 
from this provider have been covered previously and should be covered on this date of service as well. The 
Plan denied your request. The Plan says the services were obtained out-of-network and therefore are not 
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. The Plan covers the intraoral x-rays, dental cleaning and fluoride treatment when the services are rendered by a 
participating provider. 
 
We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of 
the intraoral x-rays, dental cleaning and fluoride treatment have not been met. Therefore, we decided that the 
Plan does not have to pay for the intraoral - complete series of radiographic images (D0210), prophylaxis - 
adult (D1110), and topical application of fluoride - excluding varnish (D1208) provided March 3, 2021.  
 
Your complaint about the Plan previously covering services from this provider is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with a specialist to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit with a specialist. You say that your ability to eat has been affected and you are requesting to see an OON provider for taste and swallowing. The Plan denied your request. The Plan says there is no indication to refer you to a non-network provider when services are available in-network. The Plan also says you are contractually required to obtain service from network providers.
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. The records provided for review do not show that the services at issue are urgent or emergent.
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 office visit with a specialist to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (81529) rendered by the out-of-network (OON) provider on February 19, 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 laboratory service (81529) rendered by the out-of-network (OON) provider on February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration (D4267) and bone replacement graft for ridge preservation (D7953) provided on September 9, 2020.
You asked the Plan to pay for the dental services. You say that these services were necessary and should be covered. The Plan denied your request. The Plan says that the bone replacement graft provided is not a covered service under your dental benefit. The guided tissue regeneration is an eligible service; however, it was performed at the site of a tooth extraction. Bone grafting and/or guided tissue regeneration will not be covered when it is performed at the site of a tooth extraction.
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 only covers services that are listed in the Plan's dental information guide. Bone grafting and/or guided tissue regeneration will not be covered when it is performed at the site of a tooth extraction. We looked at the file, the Plan's contract, and Medicare rules. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested bone replacement graft (D7953) is not among those listed as eligible for coverage under this benefit. The guided tissue regeneration (D4267) is an eligible service, but bone grafting and/or guided tissue regeneration is not covered when it is performed at the site of a tooth extraction. Documentation shows that you had a tooth extracted on the same date and the same tooth area as the services in question. Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for the guided tissue regeneration (D4267) and bone replacement graft for ridge preservation (D7953) provided on September 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 5, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on October 5, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections and stimulation therapy provided to the enrollee on January 28, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says these services are not covered when rendered in a chiropractic setting.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for injections and stimulation therapy provided to the enrollee on January 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the visit to the emergency department and
subsequent inpatient admission provided from November 14, 2020, to November 16, 2020.
You asked the Plan to waive the copayments for the emergency and inpatient services. You say that you do not
understand why you owe this amount for your hospital care. The Plan denied your request. The Plan says the
cost-sharing for these services was applied 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 $90
copayment per emergency visit. This copayment is not waived if you are admitted to the inpatient hospital. The
contract also says that you must pay a $225 copayment for each of the first six days of an inpatient hospital
admission.
You have been asked to pay a $540 copayment for the emergency and inpatient services. Documentation shows
that you were brought to the hospital where you were seen in the emergency department. Then, you were
admitted to the hospital for two days. ($90 + $225 + $225 = $540). 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 the visit to the emergency department and subsequent inpatient admission provided from
November 14, 2020, to November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit provided on April 16, 2021.
You asked the Plan to pay for the annual wellness visit (G0439). You say that this was your annual wellness visit which should be zero charge. The Plan denied your request. The Plan says you had an annual wellness visit on January 18, 2021.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit provided on April 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided February 4, 2021.
You asked the Plan to pay for the ambulance response. You say that you would like the claim covered. The Plan denied your request. The Plan says this service is not covered because there was no 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 February 4, 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, no transport (A0998) provided February 4, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to adjust the copayment for SNF services provided from May 19, 2020, through June 14, 2020.
You asked the Plan to adjust the copayment for SNF services. You say that the Plan approved the SNF services at the in-network benefit level and the copayment should reflect the in-network amount. The Plan denied your request. The Plan says that the claims processed correctly according to the member's 2020 SNF Plan benefits.
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 says that enrollees must pay $160 for days 21 to 100 for Skilled Nursing Facility (SNF) Care. The Plan says the enrollee must pay $175 per day for a total of 27 SNF days. Based on the plan contract, however, the enrollee cannot be asked to pay more than $160 per day for a total of 27 SNF days. Therefore, we decided that the Plan has to adjust the copayment for the SNF services from May 19, 2020, through
June 14, 2020.
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 out of network medical services provided to the enrollee on March 12, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network 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 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 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 out of network medical services provided to the enrollee on March 12, 2021.