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

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on September 6, 2019 to October 21, 2019.You asked the Plan to pay forthe nursing facility care. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not preauthorized or emergent. There were in-network providers available to render the services at issue.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 service 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 subsequent nursing facility care (99309) provided on September 6, 2019 to October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fort he train of four testing (CPT 95999) provided on May 8, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this is a bundled service.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 find that CPT code 95999 is not supported in the medical record. Specifically, CPT 95999 was reported for train of four testing. Train of four testing is not an unlisted procedure. There is a more appropriate code for train of four testing. Additionally, train of four testing is a bundled procedure and cannot be paid separately. 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 forthe train of four testing (CPT 95999) provided on May 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe unspecified procedure (D9999), the core build-up (D2950), the crown (D2740), the gingival irrigation (D4921 x2), the fluoride (D1206 x2) and the nitrous oxide (D9230) provided from September 12, 2019 to September 30, 2019.You asked the Plan to pay forthe unspecified procedure (D9999), the core build-up (D2950), the crown (D2740), the gingival irrigation (D4921 x2), the fluoride (D1206 x2) and the nitrous oxide (D9230). You say that you were told the provider was in-network.The Plan denied your request. The Plan says the services are not covered benefits.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 unspecified procedure (D9999), the core build-up (D2950), the crown (D2740), the gingival irrigation (D4921 x2), the fluoride (D1206 x2) and the nitrous oxide (D9230) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay forthe unspecified procedure (D9999), the core build-up (D2950), the crown (D2740), the gingival irrigation (D4921 x2), the fluoride (D1206 x2) and the nitrous oxide (D9230) provided from September 12, 2019 to September 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 1, 2019 by an out of network (OON) provider.You asked the Plan to pay fordrug testing. You say that you are appealing with supporting documentation.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.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 whocan 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 on November 1, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray (D0220) provided on November 4, 2019.You asked the Plan to pay for the intraoral x-ray (D0220). You say that the dentist was only do procedures that were covered under the plan. You say you were told you owed nothing when you left the facility. The Plan denied your request. The Plan says the service is not covered benefits.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 intraoral x-ray (D0220) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray (D0220) provided on November 4, 2019.Your complaint about the cleanliness of the dentist's office 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approveSNF services. The Plan denied your request. The Plan says that the enrollee does not meet the requirements because no current level of function was provided and therefore therapy needs cannot be established.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay foroffice visit services provided to the enrollee on April 30, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansayscare must be received from network providers.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 Plandoes not haveto pay foroffice visit services provided to the enrollee on April 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on August 7, 2019 by an out-of-network provider.You asked the Plan to pay for the services. You say that this service should be paid for per a medical necessity review.The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.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 services provided to the enrollee on August 7, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forintraoperative neurophysiology monitoring services provided to the enrollee on August 29, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe required primary service code was also denied in this case.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must reportservices with the appropriate CPT code.In this case, the definition of HCPCS code G0453 is "Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure)."We find that HCPCS code G0453 is not supported in the medical record. Specifically, the parent codes for this code were also denied, so this code cannot be approved. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forintraoperative neurophysiology monitoring services provided to the enrollee on August 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on July 12, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 forthe drug testing rendered to the enrollee on July 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe full mouth debridement (D4355), the lower partial dentures (D5226), or the upper partial dentures (D5225) provided from February 13, 2019 to March 23, 2019.You asked the Plan to pay forthe full mouth debridement (D4355), the lower partial dentures (D5226), and the upper partial denture (D5225). You say that you were told the providers were in-network.The Plan denied your request. The Plan says these services are not covered benefits.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 full mouth debridement (D4355), the lower partial dentures (D5226), and the upper partial denture (D5225) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay forthe full mouth debridement (D4355), the lower partial dentures (D5226), or the upper partial dentures (D5225) provided from February 13, 2019 to March 23, 2019. Your complaint about the unsatisfactory dentures and the possible Medicare fraud 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 22, 2019 by an out of network (OON) provider.You asked the Plan to pay forgenetic testing. You say that this test is covered by Medicare and you are the only provider of the test.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not covered by Medicare, prior authorization was not obtained, and the provider is out-of-network with the Plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that prior authorizationmust be obtained for all genetic testing, and the Plan's Point-of-Service (POS) benefit only covers out-of-network providers when prior authorization requirements are met. 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 forthe medical services provided on October 22, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on March 22, 2017. You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the claim was filed untimely. 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 services was not filed until July 17, 2019. 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 the services provided to the enrollee on March 22, 2017.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe tissue exam provided on April 3, 2019.You asked the Plan to waive the coinsurance forthe tissue exam. You say that the colonoscopy was done by an in-network provider. You say that you had no choice on what lab was used.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for out-of-network lab services. You have been asked to pay $70.76, which is 20% of the allowed amount for the tissue exam. The allowed amount is $353.79 (20% x $353.79 = $70.76). The tissue exam falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the provider is out-of-network. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance forthe tissue exam provided on April 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Dexcom G6 touchscreen continuous glucose monitor (CGM).You asked the Plan to pre-approve Dexcom G6 CGM. You say that you used a Dexcom monitor with your previous insurance plan and want to continue.The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this continuous glucose monitor (CGM) is not a preferred brand of the Plan and you can use the Plan's preferred CGM which is Freestyle Libre.The Plan must follow Medicare rules. Medicare rules say that the Plan may specify brands and manufacturers as preferred, and limit supply to only those preferred brands as long as the enrollee maintains access to all medically necessary items. We looked at the file and Medicare rules. The requested Dexcom G6 is not the Plan's preferred brand for continuous glucose monitor. You can use the Plan's preferred brand of Freestyle Libre. Based on this information, we decided that Medicare rules for coverage of Dexcom G6 CGM have not been met.Therefore, we decided that the Plan does not have to pre-approve use of Dexcom G6 touchscreen continuous glucose monitor (CGM)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extraction (D7210) provided on November 8, 2019.You asked the Plan to pay forthe extraction (D7210). You say that you were told that the service was covered and that your dental was paid through December 31, 2019.  The Plan denied your request. The Plan says the benefit is exhausted.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, there is a benefit limit of $1,000.The record shows the extraction (D7210) is not covered because the Plan had paid the annual maximum amount of $1,000. This means you were charged the full amount for the extraction. (D7210). Therefore, we decided that the Plan does not have to pay foran extraction  (D7210) provided on November 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 1, 2018. You asked the Plan to pay for the ambulance services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says your claim was untimely. 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 ambulance services was not filed until March 22, 2019. 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 the ambulance services provided on January 1, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Orthovisc. You asked the Plan to pre-approve a tier exception. You say that you cannot afford this medication. The Plan denied your request. The Plan says that tier exceptions only apply to Part D drugs. The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Orthovisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea Group 2 power wheelchair and accessories.You asked the Plan to providea Group 2 power wheelchair and accessories. You say that the enrollee needs a power wheelchair.The Plan denied your request. The Plan says the clinical documentation does not document problems with MRADLs and shows the enrollee uses a rollator and wheelchair.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that the enrollee does not have a mobility deficit that impairs their participation in MRADLs and their condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to providea Group 2 power wheelchair and accessories.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zilretta injections. You asked the Plan to pre-approve these services. You say that the injections have relieved your pain for four months. The Plan denied your request. The Plan says that the services are not medically necessary. 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the records show that you have knee osteoarthritis and have had success with Zilretta in the past. Relief from other steroids only lasted a few weeks and other therapies were not successful. Zilretta has provided sustained relief for several months and is appropriate therapy. The Zilretta is reasonable and medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve Zilretta injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvehelp with payments for rent, gas, and electric.You asked the Planto pre-approvethe payments. You say that this is covered per page 26 of the handbook.The Plandenied your request. The Plansayshelp with housing is not a covered benefit.The Plan must follow Medicare rules. Medicarerules say that items and services that are not medically necessary are not covered. Your request is not medical in nature. Based on this information, we decided that Medicare rules for coverage of the payments have not been met.Therefore, we decided that the Plandoes not haveto pre-approvehelp with payments for rent, gas, and electric.