Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral x-ray (D0230), and adjunctive prediagnostic test (D0431) provided on November 1, 2021.
You asked the Plan to pay for the additional intraoral x-ray and adjunctive pre-diagnostic test. You say that you
have had to change dentists 4 times in 3 years to be in network. You also say that The Plan denied your request.
The Plan says 1 intraoral x-ray is covered per calendar year. The Plan says that the frequency limit has been
exceeded. The Plan also says that adjunctive pre-diagnostic test is not listed as 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 and intraoral x-ray is listed as covered,
the frequency limit has been exceeded. The record shows that the Plan paid for an intraoral x-ray that you
received on the date of service in this case. Additionally, adjunctive pre-diagnostic test is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the additional intraoral
x-ray (D0230), and adjunctive pre-diagnostic test (D0431) provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tooth extraction (D7210) and alveoloplasty in conjunction with extractions (D7310).
You asked the Plan to pre-approve a tooth extraction and alveoloplasty in conjunction with extractions. You say that you need to have your teeth extracted to have your dentures put in. You also say you are unable to eat and you also choke when trying to eat. The Plan denied your request. The Plan says you have exceed your benefit limitation for tooth extractions. The Plan also says alveoloplasty is not a covered benefit with your 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. The Plan covers a tooth extraction and alveoloplasty in conjunction with extractions when the services are medically necessary and reasonable.
We looked at the file and Medicare rules. The records show that you were approved for 3 extractions on February 9, 2022, therefore, you have exceeded the maximum number of extractions for the plan year. The EOC confirms that an alveoloplasty in conjunction with extractions is not a covered benefit with your Plan. Based on this information, we decided that the Plan's rules for coverage of a tooth extraction and alveoloplasty in conjunction with extractions have not been met. Therefore, we decided that the Plan does not have to pre-approve a tooth extraction (D7210) and alveoloplasty in conjunction with extractions (D7310).
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 November 3, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. 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 November 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on September 11, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you believed that you were experiencing a life-threatening emergency and called the paramedics believing you needed to be transported to a hospital. You say that after being treated and calling your physician, you declined to be transported to the hospital. The Plan denied your request. The Plan says you Plan covers ambulance transportation only when you are actually transported by ambulance. Since you were not transported by this ambulance, the service is not covered under your Plan.
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 September 11, 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 ambulance response and treatment, no transport (A0998) provided on September 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visit (99335) provided on October 7, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for domiciliary or rest home visit. You say that it was medically necessary for the enrollee to receive treatment and you did not know that the facility failed to get pre-authorization. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 domiciliary or rest home visit (99335) provided on October 7, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve evaluation and treatment with an out of network (OON)
provider.
You asked the Plan to pre-approve the OON evaluation and treatment. You say that your doctor referred you to
the requested OON provider for a second opinion because they offer a less invasive procedure. You say that the
network providers you have been referred to by the Plan are not specialized in ascending aorta aneurysms and
are not good choices for treatment. The Plan denied your request. The Plan says the requested treatment can be
provided in network.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few
exceptions, enrollees must use contract providers for care.
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 OON evaluation and treatment. Our
reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found the
record indicates that the enrollee has an ascending thoracic aortic aneurysm measuring 5.5 cm. The Plan has
confirmed that it has in-network providers that treat the enrollee's condition. The Plan has a tertiary care
provider that has indicated that they treat the enrollee's condition. It is not medically necessary that the enrollee
see the requested OON provider.
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 OON evaluation and treatment have not been met. Therefore, we decided
that the Plan does not have to pre-approve evaluation and treatment with an out of network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs received on October 6, 2021.
You asked the Plan to pay for the drugs. You say that you got your medicine at the hospital because you had to wait a long time for the pharmacy to open. The Plan denied your request. The Plan says the claim was processed correctly.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs.
The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received on October 6, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found daily skilled services are not required and there is no need for intravenous medications or complex wound care. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. Provided records do not clarify why continued services in the home with home health care or in a long-term care facility on a part time basis would not be appropriate in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the colonoscopy you had on September 13, 2021.

You asked the Plan to waive the copayment for the colonoscopy. You say that this was a preventive test and someone coded it wrong. You said that your cost sharing should be $0. The Plan denied your request. The Plan says that you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees pay a $0 copayment for screening colonoscopies. 

The Plan says you must pay a $245 copayment for the colonoscopy. It appears the Plan is arguing that because this provider billed this service as a diagnostic colonoscopy that the outpatient surgery copayment applies. The burden is on the Plan to prove why its assessment of cost sharing is correct. In this case, the Plan has failed to provide any medical records in the case file submitted to us. Without such records, we cannot determine if the colonoscopy you had was ordered as a screening or a diagnostic service. None of the diagnoses billed on the claim indicate that you were having any signs or symptoms of disease prior to the colonoscopy which required workup. We find that the Plan has not met its burden of proving that this service was a diagnostic service. Because no such proof was provided, we can only assume that this provider ordered this service as a screening service. Based on the Plan contract, you cannot be asked to pay more than a $0 copayment for screening colonoscopies. Therefore, we decided that the Plan has to waive the copayment for the colonoscopy you had on September 13, 2021.

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 home health skilled nursing visits and 8 home health speech therapy visits.
You asked the Plan to pre-approve home health skilled services. You say that additional home health services are medically necessary. The Plan denied your request. The Plan says the requested home health speech therapy visits and home health skilled nursing visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 home health skilled services. Our reviewer says that the requested home health services are not medically reasonable and necessary. Our physician reviewer found based on the medical records provided there is no documentation that eight additional skilled nursing visits are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. Provided records do not document any acute or unstable medical conditions or changes in medication or treatment which would necessitate any further skilled nursing visits beyond what have already been approved. No medical notes from the enrollee's treating physician are provided documenting an order or need for additional skilled nursing services.
Furthermore, there is no documentation that eight additional skilled speech therapy visits are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration.
Provided records do not document any acute or unstable medical conditions or changes in medication or treatment which would necessitate any further skilled speech therapy visits beyond what have already been approved. No medical notes from the enrollee's treating physician are provided documenting an order or need for additional skilled speech therapy services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health skilled services have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 home health skilled nursing visits and 8 home health speech therapy visits.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from August 3, 2021, through August 5, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says that the inpatient admission was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record showed that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital care (including earlier emergency department and/or observation care) would span two midnights We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from August 3, 2021, through August 5, 2021.
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the out-of-network telehealth services you received on September 14, 2021, and October 5, 2021.
You asked the Plan to pay for the telehealth services. The Plan denied your request. The Plan says this 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 there is no coverage for out-of-network telehealth services. Review of the file shows that you were provided out-of-network telehealth services on September 14, 2021, and October 5, 2021. The Plan does not cover out-of-network telehealth services. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the out-of-network telehealth services you received on September 14, 2021, and October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (77080, 77081) provided on September 16,
2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not
payable.
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, we have confirmed that code 77081
is a column II code to column I code 77080. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.
Medicare rules also say that claims submitted where the unit of service exceeds the MUE value cannot be paid
when the MAI value is 2.
In this case, the MUE for CPT code 77080 is 1. The MAI value for this code is 2. You billed 2 units of this
code, exceeding the MUE. 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 the services (77080,
77081) provided on September 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vimpat 200MG tablet.
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says Vimpat is a self-administered drug.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vimpat 200MG tablet.
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monoferric for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements were not followed.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.
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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial of Infed and Venofer before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.
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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Monoferric for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214, 3074F, 3078F) provided on September
10, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the rendering provider is a non-participating provider and there is no
referring provider involved in these services. The Plan also says they did not authorize any services for this
provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 office visit (99214, 3074F, 3078F) provided on
September 10, 2021, by an out-of-network (OON) provider.