Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe walker provided on September 12, 2019 by an in-network provider.You asked the Plan to waive the coinsurance forthe DME. You say that while you were inpatient you received a walker on the day of discharge that you were told would be covered through the insurance.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to itsenrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the walker on September 12, 2019 by an in-network provider. You are asked to pay 20% coinsurancefor the DME. 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 forthe walker provided on September 12, 2019 by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95861) provided on August 28, 2019.You asked the Plan to pay for needle electromyography. You say that this was billed correctly.The Plan denied your request. The Plan says there is a more appropriate code for the service performed.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 95861 is needle electromyography; 2 extremities with or without related paraspinal areas.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 needle electromyography. Our reviewer says that CPT 95861 is not supported. Our physician reviewer found he documentation refers to EMG monitoring of the lower extremity. The documentation does not note EMG monitoring of the lower extremities and the technical report does not note bilateral needle placement.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography have not been met.Therefore, we decided that the Plan does not have to pay for needle electromyography (95861) provided on August 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on November 6, 2019.You asked the Plan to pay forthe orthoses and sleeves. You say that the claim should be paid.The Plandenied your request. The Plan says the medical records do not support this service.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthoses and sleeves have not been met. HCPCS Code(s) L1833-RT-KX and L2397-RT-KX -DOS November 06, 2019. Documentation submitted did not indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be verified.Healthcare Common Procedure Coding System (HCPCS) L1833-LT-KX and L2397-LT-KX remains not supported. A review of the patient's claim history shows that this patient has previously received the same item from a different provider on date of service May 28, 2019. This is prior to the 2 years which LCD L33318 and LCA A52465 determine is the reasonable useful lifetime for the equipment.Therefore, we decided that the Plan does not have to pay forbilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on November 19, 2019.You asked the Plan to pay for the DME. You say that the claim should be paid.The Plan denied your request. The Plan says the medical records do not support this service.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The records do not support the services.Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on November 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wrist hand orthosis (L3916) provided to the enrollee on December 23, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the medical records do not support this service.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. The documentation submitted did not indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay for wrist hand orthosis (L3916) provided to the enrollee on December 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean OrCam My Eye 2.0 (V2615).You asked the Plan to pre-approvethe visual aid. You say that the visual aid is medically necessary.The Plan denied your request. The Plan says the requested item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that Low vision aids (V2600, V2610, V2615) will be denied as noncovered because coverage under the Medicare prosthetic benefit is limited to persons with congenital absence or surgical removal of the lens of the eye. We looked at the file and Medicare rules. The OrCam My Eye 2.0 is not a covered benefit. Based on this information, we decided that Medicare rules for coverage of the visual aid have not been met.Therefore, we decided that the Plan does not have to pre-approvean OrCam My Eye 2.0 (V2615).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the office visit provided on November 20, 2019.You asked the Plan to waive the copayment for the office visit. You say that you were only seen for a wellness visit and nothing more. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There were no medical records or claim form with the diagnosis codes submitted to support that services in addition to an annual wellness visit were performed. Therefore, we decided that the Plan has to waive the copayment for the office visit provided by provider on November 20, 2019.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.Your complaint about the provider is tricking you to get more money 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: Partially Favorable

We decided that the Plan has to pre-approve periodontal scaling and root planing x4. We decided that the Plan does not have to pre-approve core buildup including any pins tooth #3 and crown tooth #3. You asked the Plan to pre-approve periodontal scaling and root planing x4. You say that the records provided should support the necessity of the services in dispute. The Plan says that root planing of all 4 quadrants is not medically necessary. The core build-up including any pins and crown - porcelain/ceramix substrate are not covered benefits under the plan. We decided that the Plan has to pre-approve periodontal scaling and root planing x4. 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 periodontal scaling and root planing when the services are medically necessary and reasonable. 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 periodontal scaling and root planing x4. Our reviewer says that this enrollee meets the medical necessity criteria. Our physician reviewer found the documentation of 4-6 mm pockets in all quadrants and the presence bleeding meet the criteria for coverage for periodontal scaling and root planing as a treatment of the patient's periodontal condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of periodontal scaling and root planing x4 have been met. Therefore, we decided that the Plan has to pre-approve periodontal scaling and root planing x4. We also decided that the Plan does not have to pre-approve core buildup including any pins tooth #3 and crown tooth #3. The Plan follows Medicare rules. Medicare rules say that 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. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of core buildup including any pins tooth #3 and crown tooth #3 have not been met. Therefore, we decided that the Plan does not have to pre-approve core buildup including any pins tooth #3 and crown tooth #3.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Rezum procedure.You asked the Plan to pre-approvethese 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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the Rezum procedure is indicated for symptomatic men aged 50 years and older with a prostate volume of 30 mL and 80 mL. The records do not indicate the size of theprostate. As such, the Rezum procedure is not reasonable or medically necessary at this time.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-approvea Rezum procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from July 8, 2019 through July 15, 2019 provided by an in-network provider.You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC 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).Review of the file show that you received inpatient hospital care from July 8, 2019 through July 15, 2019 by an in-network provider. You should have been asked to pay a $250 copayment per day for days 1-7 of the inpatient hospital care totaling: $1,750. However, the Medicare-allowed amount for the inpatient hospital care is less than the set $250 copayment per day, days 1-7; therefore, you have been asked to pay the lesser amount of $1,553.79 for the inpatient hospital care. Per your contract there is a $250 copayment per day required for days 1-7 for in-network inpatient hospital care. 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 inpatient hospital care from July 8, 2019 through July 15, 2019 provided by an in-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cataract surgery provided on October 15, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for cataract surgery. You say that the enrollee now lives in New York. You say that
the enrollee did not know that the her benefits were only for California. The Plan denied your request. The Plan
says no prior authorization was obtained. The Plan says these services were provided out-of-area.
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 has network providers
available who can provide 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 cataract surgery provided on October 15, 2019 by
an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on August 12, 2019.You asked the Plan to pay for train of four testing. You say that this was medically necessary.The Plan denied your request. The Plan says payment of this service is bundled into other services.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met.Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on August 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on August 29, 2019.You asked the Plan to pay fortrain of four testing. You say that this was medically necessary.The Plan denied your request. The Plan says payment of this service is bundled into other services.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met.Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on August 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on November 24, 2019.
You asked the Plan to pay for the initial hospital care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 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, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. We find that CPT code 99223 is not supported in the medical record. Specifically, this evaluation and management service was billed on the same day as another evaluation and management service. Therefore, this service is not separately reimbursable. Based on this information, we decided that Medicare rules for coverage of the initial hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on November 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forcomputed tomography (CT) scan provided out of network on December 30, 2019.You asked the Plan to pay forthis service. You say that this CT scan should be covered by the Plan.The Plan denied your request. The Plan says you 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 mustpay 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found noexception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forcomputed tomography (CT) scan provided out of network on December 30, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a repeat lumbar radiofrequency ablation.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that there must be a history of at least three months of moderate to severe pain with functional impairment.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 injection. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found it is appropriate to repeat this procedure if the pain relief lasts more than six months. In this case, it has lasted more than the required six months. The requested procedure is medically reasonable and 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 the injection have been met. Therefore, we decided that the Plan has to pre-approve a repeat lumbar radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on May 21, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that at the time of service, the enrollee informed you that he was under Medicare. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee on May 21, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 9, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that the nursing home is responsible for obtaining prior authorization.The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and requires authorization for certain services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on October 9, 2019 by an out of network (OON) provider.