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

We decided that the Plan does not have to waive the deductible for a colonoscopy (45378) provided July 14, 2020.

You asked the Plan to waive the deductible for the colonoscopy. You say that the service should be covered in full. The Plan denied your request. The Plan says the service at issue was a diagnostic colonoscopy. The correct deductible was applied.

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 there is a $125 copayment and a $750 deductible for outpatient surgical services. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $125 copayment and a $750 deductible for outpatient surgical services. This cost sharing is a contractual obligation that had not been met at the time the colonoscopy was received on July 14, 2020. The record shows the colonoscopy at issue was a diagnostic colonoscopy and not a screening colonoscopy. Therefore, we decided that the Plan does not have to waive the deductible for a colonoscopy (45378) provided July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 5, 2020, by an out-of-network provider.
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied your request. The Plan says the services were not authorized by the Plan to be performed by an out-of-network provider. The Plan states the services are not considered urgent/emergent in nature.
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 the medical services provided on June 5, 2020, by an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forhospice services (87101, 88305, 88311, 88312, 8831) providedAugust 25, 2020.You asked the Plan to pay forthe hospice services. You say that the services should be covered.The Plan denied your request. The Plan says original Medicare is liable for payment for the servicesMedicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forhospice services (87101, 88305, 88311, 88312, 8831) providedAugust 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

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 were 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 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 forthe medical services provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services (80053, 82248, 85027, 83036, 80061, P9604, 81001, 85025, P9603) provided September 20, 2019 to December 20, 2019.You asked the Plan to pay forthe lab services. You say that the services were medically necessary.The Plan denied your request. The Plan says the documentation does not support the services billed.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 80053, 82248, 85027, 83036, 80061,P9604, 81001, 85025, & P9603 are not supported in the medical record. Specifically, the records show the services were provided at a skilled nursing facility. The claim shows a place of service as laboratory. The claim must include the place of service where the specimen was obtained. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.Therefore, we decided that the Plan does not have to pay forlab services (80053, 82248, 85027, 83036, 80061, P9604, 81001, 85025, P9603) provided September 20, 2019 to December 20, 2019.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pre-approveright side spinal Radiofrequency Ablation. We decided that the Plan does not have to pre-approveleft side spinal Radiofrequency Ablation. You asked the Plan to pre-approveright side spinal Radiofrequency Ablation. You say that these services are medically necessary.The Plan says that that clarification is needed as to why a bilateral procedure is requested at this time.We decided that the Planhas to pre-approveright side spinal Radiofrequency Ablation.The Plan follows Medicare rules. Medicare rules say that Radiofrequency Ablation is covered if the above criteria have been 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 right side spinal Radiofrequency Ablation. Our reviewer says that the right sided Radiofrequency Ablation is medically reasonable and necessary. The left did not meet the criteria in 2018 and therefore, is not medically reasonable or necessary. Our physician reviewer found that the enrollee's condition meets criteria for right sided Radiofrequency Ablation.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of right side spinal Radiofrequency Ablation have been met.Therefore, we decided that the Plan has to pre-approveright side spinal Radiofrequency Ablation. We also decided that the Plandoes not have to pre-approveleft side spinal Radiofrequency Ablation.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 left side spinal Radiofrequency Ablation. Our reviewer says that theleft did not meet the criteria in 2018 and therefore, is not medically reasonable or necessary. Our physician reviewer found that the enrollee's condition meets criteria for left sided Radiofrequency Ablation.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of left side spinal Radiofrequency Ablation have not been met.Therefore, we decided that the Plan does not have to pre-approveleft side spinal Radiofrequency Ablation.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing,medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but the enrollee does not require an intensive inpatient rehabilitation therapy program. The enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to cognitive impairment. Care at theskilled nursing facility level appears to be more 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe cystoscopy and Botox injection provided on August 5, 2020.You asked the Plan to waive the cost share forthe cystoscopy and Botox injection. You say that the total cost of the procedure in May was $125. You say that it makes no sense that you should pay $475 more for the same procedure in the same calendar year.The Plan denied your request. The Plan says the cost share 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 $100 copayment for Medicare-covered surgery or other services at an in-network outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical chargesand 20% coinsurance for each Medicare-covered Part B drug and non-chemotherapy drug to treat cancer from an in-network provider. You have been asked to pay a total of $588 for the cystoscopy and Botox injection. The cystoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Botox 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 cost share forthe cystoscopy and Botox injection provided on August 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Incentive Spirometry device.
You asked the Plan to pre-approve an Incentive Spirometry device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an Incentive Spirometry device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two extractions (D7140 x2) provided on August 24, 2020.
You asked the Plan to pay for the extractions. You say that you feel this service should be covered because it was an emergency and an urgent situation. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that you enrolled, but these benefits were not active until October 1, 2020.
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 two extractions (D7140 x2) provided on August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe impacted ear wax removal provided on August 26, 2020.You asked the Plan to waive the copayment forthe impacted ear wax removal. You say that the doctor did the same procedure you previously had,and you were only charged $20. You say that you do not agree to pay $46.93.The Plan denied your request. The Plan says the copayment 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 $50 copayment for each in-network specialist visit for Medicare-covered services. You have been asked to pay $46.93, which is less than the standard $50 copayment for the impacted ear wax removal. The impacted ear wax removal falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The impacted ear wax removal is considered a surgical service that was provided by a specialist. 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 forthe impacted ear wax removal provided on August 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift mechanism and sales tax provided on May 14,
2019.
You asked the Plan to pay for seat lift mechanism. You say that you are requesting reimbursement for this
chair. The Plan denied your request. The Plan says the denial of payment for this claim is correct, because this
provider is not enrolled in the Medicare program and is not eligible for payment.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items
or services, a supplier must be enrolled in the Medicare program. The rules also say that Medicare does not
make separate payment for sales tax.
We looked at the file and Medicare rules. This provider is not enrolled in the Medicare program and is not
eligible for payment. Additionally, the reimbursement for sales tax that you requested is not payable by
Medicare. Based on this information, we decided that Medicare rules for coverage of seat lift mechanism have
not been met. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism and sales tax
provided on May 14, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forhospice services (11104, 17004, 99214) provided July 30, 2020.You asked the Plan to pay forthe hospice services. You say that the services were medically necessary.The Plan denied your request. The Plan says Original Medicare is liable for payment for these services.Medicare rules say that Original Medicare, not the Plan, is responsible forall Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forhospice services (11104, 17004, 99214) provided July 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen equipment you rented from May 26, 2020, to August 26, 2020.
You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you cannot afford this bill. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan also says that the late fee you were assessed is being handled separately. You will need to contact the Plan directly with any questions you may have about the late fee.
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 20% coinsurance for durable medical equipment. You have been asked to pay 20% coinsurance for the oxygen equipment. The oxygen equipment falls within the durable medical equipment 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 oxygen equipment you rented from May 26, 2020, to August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the porcelain/ceramic crown (D2740) for tooth #30.
You asked the Plan to pre-approve the porcelain/ceramic crown. You say that this service is medically necessary. The Plan denied your request. The Plan says the benefit is exhausted, and no coverage is available.
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 porcelain/ceramic crown once per tooth every 60 months. We looked at the file and Medicare rules. The file indicates that you previously had a paid claim for a porcelain/ceramic crown in 2019 for the same tooth. Therefore, the benefit has been exhausted. Based on this information, we decided that the Plan's rules for coverage of the porcelain/ceramic crown have not been met. Therefore, we decided that the Plan does not have to pre-approve the porcelain/ceramic crown (D2740) for tooth #30.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe outpatient services provided on February 19, 2020.You asked the Plan to waive the cost share forthe services provided. You say that you paid what you were initially billed.The Plan denied your request. The Plan says the claim was processed according to 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). Your contract with the Plan clearly says that you must pay a 20% coinsurance for each Medicare-covered outpatient hospital visit and hospital outpatient surgical facility. The file shows that you received a colonoscopy with lesion removaland a biopsy. You have been asked to pay a 20% coinsurance for the services provided. The services fall within the outpatient surgery 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 cost share forthe outpatient services provided on February 19, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray and emergency treatment of dental pain provided on August 31, 2020.You asked the Plan to pay forthe first intraoral periapical x-ray and emergency treatment. You say that prior to this date of service, you contacted the Plan and were told that the providing dental clinic was in-network with your plan.The Plan denied your request. The Plan says these services 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.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 forthe first intraoral periapical x-ray and emergency treatment of dental pain provided on August 31, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea seated elliptical (exercise equipment).You asked the Plan to pre-approveexercise equipment. You say that physical therapy did not work, and this equipment would be more efficient and safer than going to a gym or physical therapy.The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this exercise equipment is not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea seated elliptical (exercise equipment).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sildenafil Citrate 20 mg tablet.
You asked the Plan to pre-approve Sildenafil tablet. You say that this treatment is medically necessary. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Sildenafil Citrate 20 mg tablet.