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

We decided that the Plan does not have to pay the in network rate for D4341, D1999, D4921, D9910, and D0901 provided on September 25, 2020.
You asked the Plan to pay the in network rate for the D4341. You say that the entire bill should be covered. You say that you did not know that you could not use out of network providers with your PPO dental plan. You say that you do not have the money to pay the remaining amount. You also say that this should not be your responsibility since you have an allowance of $2,500 for dental and feel that you have not exceeded that amount. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that out of network providers are paid up to the annual maximum charge. The Plan also says that out of network providers can bill you for the difference between what was billed and what was paid.
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 services are listed as covered, dental services that you receive out of network may cost more. The record shows that the Plan paid the Maximum Allowable Charge of $96 for D4341 for the upper right and lower right quadrants. The Evidence of Coverage states that out of network providers can bill you for the difference between what was billed and what was paid. Therefore, we decided that the Plan does not have to pay the more for D4341, D1999, D4921, D9910, and D0901 provided on September 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99204) provided on April 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you are being billed by the provider in the amount of $149 and you feel you should not be responsible for this date of service. The Plan denied your request. The Plan says a corrected claim was not submitted. Enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99204) provided on April 14, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the comprehensive evaluation and management provided on January 27, 2021.
You asked the Plan to waive the copayment for the comprehensive evaluation and management. You say that this was for an annual physical exam which is fully covered once every year. 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 $45 copayment for specialist physician services. You have been asked to pay a $45 copayment for the comprehensive evaluation and management. The comprehensive evaluation and management falls within the Physician/Practitioner services, including doctor's office visits benefit category. The billed service is not considered a zero-cost preventive service with Medicare. 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 comprehensive evaluation and management provided on January 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, chest (71045-26) provided
January 26, 2021.
You asked the Plan to pay for the diagnostic services. You say that this service was performed twice on the
same day by the same physician at two different timings. You are requesting reconsideration of the
determination by reviewing the attached radiology reports and process for payment. The Plan denied your
request. The Plan says procedure code 71045 is a column II procedure to the column I procedure 32557-RT
which was processed and paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045
has a bundled relationship with code 32557-RT and cannot be paid as billed. This code cannot be paid as a
separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the radiologic examination, chest (71045-26) provided January
26, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for transthoracic echocardiography, real-time with image documentation (2D), includes M-mode recording (93306) provided November 17, 2020.
You asked the Plan to waive the copayment for the transthoracic echocardiography. You say that you were not aware you had to pay a copay for your echocardiogram. In the past you paid a copay of $30 for the follow up appointment to discuss the results. Hopefully this $110 copay can be reduced or eliminated. The Plan denied your request. The Plan says the claim was processed, and the correct copayment was applied per the 2020 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 $110.00 copayment for each radiological diagnostic service, not including x-rays, performed in a physician's office or a freestanding facility. for Outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay $110.00 copayment for each radiological diagnostic service, not including x-rays, performed in a physician's office or a freestanding facility. for the transthoracic echocardiography. the transthoracic echocardiography falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 transthoracic echocardiography, real-time with image documentation (2D), includes M-mode recording (93306) provided November 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Modafinil 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 Modafinil 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM).
You asked the Plan to preapprove the CGM. You say that you believe this device should be covered because you check your blood sugar at least three times per day. The Plan denied your request. The Plan says you do not meet coverage criteria as you are not using insulin three times or more per day.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided by a participating provider on August 11, 2020.
You asked the Plan to waive the copayment for a diagnostic ultrasound. You say that you do not recall having this copayment in the past. The Plan denied your request. The Plan says the correct copayment has been applied.
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 outpatient diagnostic tests/in-network/diagnostic radiological services. You have been asked to pay $45.70 which is less than your copayment amount of $100 for a diagnostic ultrasound. The total amount you are being asked to pay is $91.40 ($45.70 x 2 ultrasounds = $91.40). The ultrasounds that were provided were diagnostic in nature; therefore, the correct copayments have been applied). A diagnostic ultrasound falls within the outpatient diagnostic tests/in-network/diagnostic radiological 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 a diagnostic ultrasound provided by a participating provider on August 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the chest and abdomen for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the results of a tissue sample taken for lab testing was not received.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. Despite a request to the treating provider, the plan did not receive any medical records to indicate why this request was needed. The medical necessity of this scan cannot be determined. Based on this information, we decided that Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the chest and abdomen for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on November 13, 2020.
You asked the Plan to pay for the laboratory services. You say that you rely on the referring physicians to provide you with all the necessary information for the claims to be processed. You say that the services were medically necessary, and the denial should be reconsidered for payment. The Plan denied your request. The Plan says care received from a non-network provider will not be covered.
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 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 laboratory services provided by an out-of-network provider on November 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0481) provided to the enrollee on August 3, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0481 (1 Unit) and Current Procedural Terminology (CPT)code 80307 (1 Unit) remain unsupported.
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 80307 and HCPCS G0481 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0481) provided to the enrollee on August 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the prophylaxis (D1110), and the complete series x-ray (D0210) provided on December 18, 2020.
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services provided out of network 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, dental services performed out of network are not among those covered under this benefit. The record shows that the Plan reached out to the provider who advised they would provide a discount for the services to be paid out of pocket. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the prophylaxis (D1110), and the complete series x-ray (D0210) provided on December 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this medication was denied as a benefit exclusion.
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 Dupixent for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric admission.

You asked the Plan to pre-approve inpatient psychiatric admission. You say that the enrollee did not have the option of going to another facility as he had been in an acute care hospital prior to admission. It was determined by the court that this enrollee needed further psychiatric care at the State Hospital. The Plan denied your request. The Plan says the records do not support that the guidelines for acute inpatient psychiatric treatment have been met.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 inpatient psychiatric admission. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond the dates in question. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. I am unable to find an individualized treatment plan however the entire record is not present. It appears that the services were supervised and evaluated by a physician. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of April 14, 2021 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations (other than mumbling voices), delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options (K0861) and accessories (E2361, E1028, E2377, E2313, E1007, E2311, E0955, E1028, E1012, E2607, E2620).

You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options and accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not require the specific wheelchair requested.

The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with Multiple Power Options (K0861) is covered only if the enrollee the beneficiary meets coverage criteria for a power tilt and recline seating system or uses a ventilator which is mounted on the wheelchair. Options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself 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 a group 3 power wheelchair with multiple power options and accessories. Our reviewer says that the criteria for coverage of the requested power wheelchair have not been met. Our physician reviewer found the documentation does not support that you require a ventilator, power tilt, or power recline.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a group 3 power wheelchair with multiple power options and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair
with multiple power options (K0861) and accessories (E2361, E1028, E2377, E2313, E1007, E2311, E0955, E1028, E1012, E2607, E2620).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you have extreme foot pain, trouble walking, and you have been falling. 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 pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee.

You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says covered alternatives would be a fixed height or variable height hospital bed.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or

2. Requires attachments which can only be attached to a hospital bed; AND

3. Requires frequent changes in body position and/or has an immediate need for a change in body position.

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 bed. Our reviewer says that the requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does not clearly reveal that enrollee's condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary bed.

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 bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2740) and core build up (D2950)
for tooth # 2.

You asked the Plan to pre-approve the dental services. You say that these services are medically necessary for
the enrollee. The Plan denied your request. The Plan says porcelain crown is not listed as a covered service.
The Plan says that core build up is not listed as a covered service either.

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 pre-approve a
porcelain crown (D2740) and core build up (D2950) for tooth # 2.