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

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.  You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is medically necessary. The Plan denied your request. The Plan says the requested continued SNF care 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found daily skilled services are not required. Despite daily skilled therapy since January 18, 2022, the enrollee has made no significant progress. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an electric scooter (K0800).  You asked the Plan to pre-approve the electric scooter. You say that the power scooter is medically necessary. The Plan denied your request. The Plan says no physician order has been provided for this equipment.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid physician order. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pre-approve an electric scooter (K0800).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the insertion of a bladder catheter (51701) provided from August 12, 2021, to September 14, 2021.

You asked the Plan to waive the copayment for the insertion of a bladder catheter. You say that the services should be covered as you want to know what they are for. The Plan denied your request. The Plan says the cost-sharing applied correctly as these services were billed as an outpatient hospital/treatment room/insertion of bladder catheter.

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 $150 copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers.

You have been asked to pay a $150 copayment for an insertion of a bladder catheter. Insertions of a bladder catheter fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 the insertion of a bladder catheter (51701) provided from August 12, 2021, to September 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for an electric scooter (K0800).  You asked the Plan to pay for the electric scooter. You say that the scooter is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid physician order. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for an electric scooter (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554) and related supplies (K0553).  You asked the Plan to pre-approve a continuous glucose monitor and related supplies. You say that the requested items are a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for continuous glucose monitors and related supplies have not been met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. No medical documentation was provided to indicate whether you use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, and have had an in-person visit with your treating physician to assess adherence to your CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554) and related supplies (K0553).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0482) provided on July 8, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says both the referring and attending providers are all non-participating with the Plan, and the non-participating provider did not follow the plan's rules to request 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 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 drug testing (G0482) provided on July 8, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve ten (10) additional OT visits.  You asked the Plan to pre-approve ten (10) additional OT visits. You say that additional OT is medically necessary. The Plan denied your request. The Plan says additional OT is not medically necessary.  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 ten (10) additional OT 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 that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has 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. 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 the enrollee's 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 ten (10) additional OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional OT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the remote monitoring of a wireless pulmonary artery pressure sensor (93264) rendered by the out-of-network (OON) provider on September 30, 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 remote monitoring of a wireless pulmonary artery pressure sensor (93264) rendered by the out-of-network (OON) provider on September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the apicoectomy - premolar (first root) (D3421) and retrograde filling - per root (D3430) provided October 5, 2021.  You asked the Plan to pay for the apicoectomy and retrograde filling. You say that you were given incorrect information by a customer service representative. The Plan denied your request. The Plan says these services are not covered under your benefits. A review of the phone records shows that information was provided regarding a different service, but no information was requested or provided for the services which were billed.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the apicoectomy - premolar (first root) (D3421) and retrograde filling - per root (D3430) provided October 5, 2021.   Your complaint about potentially receiving incorrect or incomplete information from a plan representative 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse an additional amount for the crowns (D2740 x 2) provided from May 25, 2021, to July 9, 2021.  You asked the Plan to reimburse an additional amount for the dental services. You say that the provider fraudulently submitted 2 different claims to your insurance. You say that your dentist advised you would be refunded $259. You say that that is only 22% of the $1,160 cash payment that you have made. You also say that the provider deducted $133 from that for a previous balance not covered when you were under a different plan. The Plan denied your request. The Plan says there is a 50% coinsurance for crowns when performed in network. The Plan also says that the cost share was applied correctly.    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 crowns are listed as covered, there is a 50% coinsurance that applies when performed in network. The record shows that the allowed amount for 1 crown is $901. $901 x 50% coinsurance = $450.50. $450.50 x 2 crowns = $901. The record shows that you paid a total of $1,160 out of pocket for the crowns. $1,160 - $901 = $259 reimbursement amount. Therefore, we decided that the Plan does not have to reimburse an additional amount for the crowns (D2740 x 2) provided from May 25, 2021, to July 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on February 23, 2021 by a Medicare opt out provider.  You asked the Plan to pay for the prophylaxis. You say that you would like the original claims to stand as they originally were promised as part of the coverage and paid as such. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective November 1, 2015, to November 1, 2023.  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 covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on February 23, 2021 by a Medicare opt out provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for colonoscopy and biopsy services provided on May 28, 2021.  You asked the Plan to waive the copayment for the colonoscopy and biopsy services. You say that the services should be covered as they were screening services. The Plan denied your request. The Plan says According to current Medicare rules, when polyps are removed and sent to a pathologist for a diagnosis, it is no longer a preventive screening test. It requires more time and effort to remove the polyp and stop any bleeding. This decision is in accordance with the Medicare publication titled, MLN Matters Number: SE0746 and SE0710. It states, `if during the course of such screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the lesion or growth, payment under this part shall not be made for the screening colonoscopy but shall be made for the procedure classified as a colonoscopy with such biopsy or removal.''  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 $150 copayment for Outpatient hospital services.   You have been asked to pay a $150 copayment for the colonoscopy and biopsy services. Colonoscopy and biopsy services fall within the Outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for colonoscopy and biopsy services provided on May 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for pulse oximetry testing you had on October 7, 2021.  You asked the Plan to waive the copayment for the pulse oximetry testing. You say that this copayment should be waived because it is related to Coronavirus Disease 2019 (COVID-19). The Plan denied your request. The Plan says it incorrectly assessed a deductible for this service, but that has been corrected.  You are now only responsible for a $10 copayment for this service.  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 $10 copayment for diagnostic tests.   You have been asked to pay a $10 copayment for the pulse oximetry testing. The pulse oximetry testing falls within the diagnostic tests benefit category. The Plan's website says that the only copayments being waived are for COVID-19 vaccines, testing for COVID-19, and virtual visits for the diagnosis of suspected COVID-19.  For all other services, the cost sharing applies as is listed in your Evidence of Coverage.   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 pulse oximetry testing you had on October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for hearing aids provided on April 15, 2021.  You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says customers are required to contact the Plan's hearing vendor to receive the benefit.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plan's hearing vendor.  We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 14, 2021.

You asked the Plan to pay for the dental service. You say that this service should be covered. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage and the service is listed as covered, the frequency limits has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on August 11, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an interrogation device evaluation (93298, G2066) provided on October 18, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an interrogation device evaluation. You say that the patient is unable to seek the correct primary care provider to sign their orders. You also say that the services to the patient are medically necessary. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they also have determined that these services are not urgent or emergent, nor were they approved in advance.  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 interrogation device evaluation (93298, G2066) provided on October 18, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 21, 2021.  You asked the Plan to pay for the dental service. You say that you were charged for a comprehensive oral exam on October 20, 2020 but you only had a routine exam and cleaning done that day. You also say that you did not exceed your benefit limitation. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 36 months. The Plan also says that the frequency limit has been exceeded.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage and the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation you received on October 1, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Aricept for the enrollee.  You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.  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 Aricept for the enrollee.       Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.