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

We decided that the Plan does not have to pay for surgical assistant services (29827, 29823, 29826) provided October 13, 2020.
You asked the Plan to pay for the surgical assistant services. You say that the services were medically necessary. The Plan denied your request. The Plan says this type of provider is not eligible for payment.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services (29827, 29823, 29826) provided October 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a root canal (endodontic therapy) (D3320), treatment of a root canal obstruction (D3331) and retreatment of a previous root canal therapy (D3347) provided on December 4, 2020 and December 18, 2020.
You asked the Plan to pay for the root canal services. You say that these services are medically necessary, and you require extensive dental work due to a medical condition. These services are costly, and you do not feel your benefits were clearly explained to you. The Plan denied your request. The Plan says root canals can only be covered once per year. The Plan paid for a root canal for you in May of 2020. Therefore, on the date in question, your benefit for root canal services had already been exhausted and payment cannot be made. In addition, treatment of a root canal obstruction and retreatment of a previous root canal therapy are not covered by Medicare or the Plan's supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 or were provided in a frequency that exceeds what is covered by the Plan. Therefore, we decided that the Plan does not have to pay for a root canal (endodontic therapy) (D3320), treatment of a root canal obstruction (D3331) and retreatment of a previous root canal therapy (D3347) provided on December 4, 2020 and December 18, 2020.
Your complaint about possible misinformation from a Plan-contracted provider and their understanding of what is covered 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a Positron Emission Tomography (PET) scan (78815) provided August 25, 2020.
You asked the Plan to pay for the PET scan. You say that the scan was medically necessary. The Plan denied your request. The Plan says coverage criteria was not met.
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 78815 is not supported in the medical record. Specifically, the claim was not billed with a valid diagnosis code for a PET scan. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for a Positron Emission Tomography (PET) scan (78815) provided August 25, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on December 7, 2020.

You asked the Plan to waive the copayment for these services. You say that you had a routine colonoscopy and should have no copayment. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for each visit to an ambulatory surgical center.

Review of the file shows that you received a diagnostic colonoscopy on December 7, 2020. The file shows that the colonoscopy was diagnostic and not screening in nature because specimens were collected during the procedure. You have been asked to pay a $200 copayment for these services. These services fall within the visit to an ambulatory surgical center 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 outpatient surgical services rendered on December 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on October 20, 2020.
You asked the Plan to pay for foot orthotics. You say that you have had multiple surgeries, and this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on October 20, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Nucala.

You asked the Plan to pre-approve Nucala. You say that the medication is necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Nucala. Our reviewer says that the medication is medically necessary. Our physician reviewer found the enrollee has a history of using Nucala with benefit according to the records and is requiring multiple other medications to achieve sufficient control of symptoms. Nucala is FDA approved for the enrollee's condition. Therefore, the request for Nucala will be considered medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nucala have been met. Therefore, we decided that the Plan has to pre-approve Nucala.

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 fourteen (14) skilled nursing visits.
You asked the Plan to pre-approve skilled nursing visits. You say that you need help to take care of the wounds
on your feet. The Plan denied your request. The Plan says the services are not 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 skilled nursing visits. Our physician
reviewer found based on the documentation provided, the health plan's denial should be upheld. You do not
have documented skilled nursing needs. You have wounds on your foot, which are small in size and receiving
only basic wound care. A skilled nurse is not required to tend to these wounds. As such, the requested home
health skilled nursing services are not medically necessary or reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of skilled nursing visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve fourteen (14) skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total hip replacement (CPT code 27130).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not 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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding significant left hip pathology. Furthermore, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for the left total hip arthroplasty is not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve total hip replacement (CPT code 27130).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the mammograms and the diagnostic
digital breast tomosynthesis provided on September 23, 2020 and September 25, 2020.
You asked the Plan to waive the copayments for the mammograms and the tomosynthesis. You say that this
was your annual mammogram, and it should have been paid by insurance. You say you had breast cancer and
your doctor will not change the diagnostic codes. The Plan denied your request. The Plan says you have been
asked to pay the correct cost-sharing amount.
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 $110
copayment for each covered x-ray in the outpatient department of a network hospital or facility and a $150
copayment for each covered diagnostic procedure or test at a network outpatient facility.
You have been asked to pay a $110 copayment for the mammograms on each date of service and a $23.12
copayment, which is less than the standard copayment, for the tomosynthesis on each date of services. ($110 +
$110 + $23.12 + $23.12 = $266.24). The mammograms and the tomosynthesis fall within "Outpatient
diagnostic tests and therapeutic services and supplies" benefit category. The record shows a history of breast
cancer which makes the services diagnostic in nature.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayments for the mammograms and the diagnostic digital breast
tomosynthesis provided on September 23, 2020 and September 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department visit (99285) provided October 16, 2019.
You asked the Plan to pay for the emergency visit. You say that you did not have the payer that the claim needed to go to, so you billed the enrollee. Please review all attached information and reprocess this claim for payment. The Plan denied your request. The Plan says the claim was received past the timely filing limitation.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the emergency visit was not filed until 11/02/2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for emergency department visit (99285) provided October 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on November 8, 2020.

You asked the Plan to waive the copayment for emergency room visit. You say that you are disputing this charge. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $80 copayment for emergency room visit. 

You have been asked to pay $80 copayment for emergency room visit. Emergency room visit falls within the Emergency Care 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 an emergency room visit provided on November 8, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a panniculectomy procedure.

You asked the Plan to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy);
abdomen, infraumbilical panniculectomy (15830). You say that the removal of excess skin will help the
excoriations and repeated infections. The Plan denied your request. The Plan says that it has not been more
than a year since the weight loss and records do not show the skin problems have not gotten better with nonsurgery
treatment.

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 excision, excessive skin and
subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy (15830). Our reviewer says
that the requested services are considered medically reasonable and necessary in this case. Our physician
reviewer found the physical examination demonstrates scars and skin excoriations. Submitted photographs
demonstrate a pannus that extends to the upper thigh. The requested procedure is medically reasonable and
necessary. The elements of the coverage determination are satisfied. The requested service is recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of excision, excessive skin and subcutaneous tissue (includes lipectomy);
abdomen, infraumbilical panniculectomy (15830) have been met. Therefore, we decided that the Plan has to
pre-approve a panniculectomy procedure.

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 psychiatric services provided on September 29, 2020, by
an OON provider.

You asked the Plan to pay for the psychiatric services. You say that the services were medically necessary. The
Plan denied your request. The Plan says no prior authorization was obtained.

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 the psychiatric services provided on September
29, 2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra heavy-duty hospital bed.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that an extra heavy-duty hospital bed is covered if the beneficiary meets one of the criteria for a hospital bed and the beneficiary's weight exceeds 600 pounds.

We looked at the file and Medicare rules. The records show that your weight does not exceed 600 pounds. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an extra heavy-duty hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a tubing with heating element (A4604), nasal interface (A7034), and filter (A7038) for use with a CPAP device, provided on January 11, 2021.
You asked the Plan to waive the deductible for a tubing with heating element, nasal interface, and filter. You say that the cost of the requested items should be covered by the Plan. The Plan denied your request. The Plan says the correct cost-sharing 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 $203 deductible for durable medical equipment (DME) and related supplies. The item or service you asked the Plan to waive the deductible for falls within the benefit category "Durable medical equipment (DME) and related supplies." The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible for durable medical equipment (DME) and related supplies. This cost sharing is a contractual obligation that had not been met at the time a tubing with heating element, nasal interface, and filter were received on January 11, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a tubing with heating element (A4604), nasal interface (A7034), and filter (A7038) for use with a CPAP device, provided on January 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical colonoscopy (45390, 45380) provided November 30, 2020.

You asked the Plan to waive the copayment for the outpatient procedure. You say that you were advised that the colonoscopy was a routine procedure and there was no copay. After the colonoscopy you were told that a polyp was removed and now you receive a bill for $200. You should have been asked if you wanted the polyp removed. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.

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 $200 copay per visit, per provider per day for outpatient surgery performed in an ambulatory surgical center. 

You have been asked to pay $200 copay for the outpatient procedure. The outpatient procedure falls within the Outpatient surgery, including 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 outpatient surgical colonoscopy (45390, 45380) provided November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 9, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers available for these 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 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 physician services provided on December 9, 2020 by an out of network (OON) provider.