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

We decided that the Plan does not have to pay for the oral surgery services rendered to you on September 24, 2019.
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 provider has opted out of Medicare.
The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given by a physician or other practitioner who has opted out of Medicare. We looked at case file and the Medicare rules. We confirmed that the provider has opted out of Medicare. The file shows that the Plan approved for you to be seen by this provider for one visit, and this visit was used on September 10, 2019. The file shows that you saw this provider again on September 24, 2019 and signed an Opt-Out Waiver Form acknowledging that the provider had opted out of Medicare coverage. 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 pay for the oral surgery services rendered to you on September 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment formyocardial imaging provided on January 22, 2020.You asked the Plan to waive the copayment formyocardial imaging. You say that you were told that you would not owe a copayment.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $300 copayment for advanced imaging and nuclear medicine. You have been asked to pay a $300 copayment for myocardial imaging. Myocardial imaging 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 formyocardial imaging provided on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says step therapy (for this drug) encourages you to try zoledronic acid, which is just as effective.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of Zoledronic acid. There is no evidence of osteoporosis-related fracture. The documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee 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 the drug have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the surgery provided on November 13, 2019.You asked the Plan to waive the copayment for the surgery. You say that you have never been charged copayments for your skin cancer removals and have always used the same treatment space. The Plan denied your request. The Plan says you have been charged 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 $300 copayment for all other outpatient services not provided in an ambulatory surgical center. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $300 copayment for the surgery.You have been asked to pay a $268.86 copayment for the surgery. The surgery 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 surgery provided on November 13, 2019.Our decision is only about the November 13, 2019 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on January 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency 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 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 services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to you by an out-of-network provider on
January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 10, 2019 by an out of network (OON) provider.You asked the Plan to pay for the OON services. You say that the provider did not know the enrollee was out of network.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 on October 10, 2019 by an out of network (OON) provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 19, 2019.
You asked the Plan to pay for the ambulance services. You say that you called 911 back to say you felt better but they sent the ambulance anyway. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 19, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on September 26, 2019.
You asked the Plan to pay for lab tests. You say that you are appealing with attached information. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a physician order or laboratory requisition to support the services billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on September 26, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fortrain of four monitoring (95937) provided on June 26, 2019.You asked the Plan to pay forthe train of four monitoring. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says it is inappropriate to bill the code for neuromuscular junction testing for train of four monitoring.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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.We find that CPT code 95937 is not supported in the record. Specifically, train of four monitoring does not meet the CMS guidelines of CPT code 95937 for neuromuscular junction testing. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met.Therefore, we decided that the Plan doesnot have to pay fortrain of four monitoring (95937) provided on June 26, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2750) for tooth number 10.
You asked the Plan to pre-approve a porcelain crown. You say that the enrollee was testing bite stick positive with a vertical fracture. To properly restore the tooth a crown is needed. The Plan denied your request. The Plan says the tooth does not appear to have significant breakdown. The submitted information does not demonstrate that there is pathologic destruction to more than 50 % of the incisal edge and/or 4 or more surfaces of the tooth.
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 a dental crown 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 a porcelain crown for tooth number 10. Our reviewer says that this tooth does not meet criteria for coverage of a porcelain crown. Our physician reviewer found that the tooth has an apparent previously placed amalgam restoration on either the lingual or facial surface as well as very small mesial composite restoration. The amount of total missing structure is less than 25% and does not involve the incisal edge. In this case, there is insufficient damage to the tooth to meet criteria, and there is no involvement of the incisal edge. The tooth does not need to gain strength from a full coverage crown as there is minimal missing structure. Given the presentation of tooth #10, there is no medical necessity for a crown. We looked at this physician's review, the file, and Plan's rules. Based on this information, we decided that the Plan's rules for coverage of a porcelain crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D2750) for tooth number 10.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power wheelchair and attachments.You asked the Plan to pre-approvethese services. You say that thiswill help you get around the community.The Plan denied your request. The Plan says that there is no documentation that the member is unable to perform mobility related activities of daily living or that her needs could not be met with use of a walker.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea power wheelchair and attachments.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 25, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the services in dispute were medically necessary. The Plan denied your request. The Plan says the non-network provider does not work with the enrollee's health plan. The Plan says that the enrollee was no referred for the services by her primary care physician. The Plan says that there is no network deficiency for the services and that the out of network services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider at issue in this case is not a network provider with the Plan. 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 the subsequent nursing facility care. Our reviewer says that Our physician reviewer found 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 subsequent nursing facility care have not been met.
The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pay for the subsequent nursing facility care. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 25, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 8, 2019 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
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The
Plan says that the primary care physician did not refer 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 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 physician services provided on November 8, 2019
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper dentures.
You asked the Plan to pre-approve the complete upper dentures. You say that the dentures you previously received never fit right. You say that the provider never informed you that the dentures would not be covered. The Plan denied your request. The Plan says the time limit for coverage of dentures has not yet passed.
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 benefit for coverage of complete dentures is limited to once every 5 years. The records show that you previously received coverage for complete dentures provided on October 2, 2017. This means that you have already received coverage for complete dentures within the last 5 years, and that your benefit for complete dentures is currently exhausted. Therefore, we decided that the Plan does not have to pre-approve complete upper dentures.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe digital breast tomosynthesis rendered on December 5, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 77062 is not payable.The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. The provider submitted a claim for procedure code 77062 and this code hasa status indicator of I and is not valid for Medicare purposes.Therefore, we decided that the Plan does not have to pay forthe digital breast tomosynthesis rendered on December 5, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services rendered on August 8, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that home health episode payments must be based upon the site at which the beneficiary is served.We looked at the file and Medicare rules. The file shows that the claim was not billed with the correct county code to identify where the services were rendered. Based on this information, we decided that Medicare rules for coverageof these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home health services rendered on August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve a total electric hospital bed. The Plan denied your request. The Plan says that total electric hospital beds are considered not reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tdap, Hepatitis A and Hepatitis B, and Typhoid vaccines you received on November 8, 2019.
You asked the Plan to pay for the vaccines. You say that you needed the vaccines for traveling. The Plan denied your request. The Plan says these vaccines are not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccines. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccines. Therefore, we decided that the Plan does not have to pay for the Tdap, Hepatitis A and Hepatitis B, and Typhoid vaccines you received on November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (CPT 95999) provided to the enrollee on August 26, 2019.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says Medicare does not make separate payment for CPT 95999.
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 95999 is "Unlisted neurological or neuromuscular diagnostic procedure." We asked our coding 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 the testing. Our reviewer says that the services at issue in this case were not supported by the records. Our coding reviewer found the medical records provided do not include documentation of an unlisted neurological or neuromuscular diagnostic procedure being performed on August 26, 2019, therefore this service cannot be verified. The operative report indicates that Train of Four Testing was performed. Train of Four Testing is inclusive to the IONM, whether the IONM is primarily EMG based or MEP based. There is no CPT code available for use for Train of Four Monitoring, therefore it is inappropriate to use CPT 95999 for Train of Four Monitoring. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (CPT 95999) provided to the enrollee on August 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe lab services you received on December 20, 2019.You asked the Plan to waive the copay for the lab services. You say that you haven't had a copay in 3 years for these tests.The Plan denied your request. The Plan says the claim processed correctly based on your 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 $10 copay for diagnostic lab services. You have been asked to pay a $10 copay for the lab services. The services fall within the outpatient diagnostic tests 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 copay for the lab services you received on December 20, 2019.