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

We decided that the Plan does not have to pay forthe panoramic x-ray (D0330) provided on February 11, 2019.You asked the Plan to pay forthe dental service. You say that the benefits book clearly states that all dental x-rays are 100% covered by the Plan. You also say that the benefits book does not specify in detail any exclusions in the plan for any different types of x-rays.The Plan denied your request. The Plan says panoramic x-ray is not listed as a covered service.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 panoramic x-ray is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe panoramic x-ray (D0330) provided on February 11, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance forthe Part B injection provided on August 5, 2019.You asked the Plan to reduce the coinsurance for the Part B injection. You say that this coinsurance amount is a financial hardship. The Plandenied 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 20% coinsurance for in-network Medicare Part B covered drugs. You have been asked to pay a total of $913.47 which is 20% of the total allowed amounts for the Part B injection. The total allowed amounts are $4,567.33. ($4,567.33 x 20% = $913.47). the Part B injection falls within the in-network Medicare Part B covered drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the coinsurance forthe Part B injection provided on August 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on December 26, 2019 with a right femur fracture and underwent open reduction internal fixation (ORIF). She is now non-weight bearing to the right leg and is ambulating 50 feet with contact guard/minimal assist and a right knee immobilizer as of January 17, 2020. She has no complex medical, nursing, or rehabilitation needs that require an acutehospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit from further therapy but does not require an intensive therapy program in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe esophagus biopsy and dilation provided on August 15, 2019 and the office visit provided on August 29, 2019.You asked the Plan to waive the copayments forthe esophagus biopsy, the esophagusdilation and office visit. You say that you were informed prior to the procedure that there was no copayment. You say that you don't understand the bills.The Plan denied your request. The Plan says the copayments 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 $250 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility and a $35 copayment per specialist visit.You have been asked to pay a total of $285 for the esophagus biopsy, the esophagusdilation and office visit. The esophagus biopsy and dilation fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 copayments for the esophagus biopsy and dilation provided on August 15, 2019 and the office visit provided on August 29, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for custom fabricated abutment -includes placement (D6057), local anesthesia in conjunction with operative or surgical procedures (D9215) and crown -porcelain fused to high noble metal (D2750) provided on September 12, 2019.You asked the Plan to pay forthe dental services. You say that the services are medically necessary.The Plan denied your request. The Plansays the services are not a covered benefit under the plan.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. The services are not a covered benefit under the plan and the tooth had been previously extracted.Therefore, we decided that the Plan does not have to pay forcustom fabricated abutment -includes placement (D6057), local anesthesia in conjunction with operative or surgical procedures (D9215) and crown -porcelain fused to high noble metal (D2750) providedon September 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on September 19, 2019, by an out-of-network provider.You asked the Plan to pay forthe services. You say that the services were rendered in good faith as you have an exclusive contract with the nursing facility where the enrollee resides.The Plan denied your request. The Plan says services from an out-of-network provider are not covered unless preauthorized.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. The Health Plan confirmed the enrollee was a long term care resident of the non-contracted assisted living facility. The Health Plan confirmed no skilled nursing services were performed.Therefore, we decided that the Plan does not have to pay forthe services provided to the enrollee on September 19, 2019, by an out-of-network provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea hysterectomy for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no clinical documentation showing a trial of conservative measures of treatment.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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found hysterectomy is generally recommended for women with persistent bothersome symptoms of endometriosis who have failed both medical therapy and at least one conservative surgery or for women who have additional indications for hysterectomy. The documentation in the case file is insufficient to demonstrate that an adequate trial of conservative treatment has been tried and failed.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 Plandoes not haveto pre-approvea hysterectomy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forspecialist services provided on September 18, 2019.You asked the Plan to waive the copayment forthe specialist services. You say that you have never paid two copayments in the past.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC 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). Review of the file show that you received specialist services provided on September 18, 2019. Youare asked to pay a $25 copayment for the services. 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 forspecialist services provided on September 18, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral -periapical first radiographic image (D0220) provided on October 1, 2019.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the service is not a covered benefit under the plan.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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Your plan only covers bitewing x-rays.Therefore, we decided that the Plan does not have to pay forintraoral -periapical first radiographic image (D0220) provided on October 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the mammogram, the ultrasounds, or the laboratory work provided on July 30, 2019.You asked the Plan to waive the coinsurance for the mammogram, the ultrasounds, and the laboratory work. You say that you think all of the diagnostic services should be considered preventive 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 20% coinsurance for diagnostic radiology and 20% coinsurance for laboratory tests. You have been asked to pay a total coinsurance amount of $163.52 for the mammogram, the ultrasounds, and the laboratory work. The mammogram, the ultrasounds, and the laboratory work fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows the mammogram was ordered due to an abnormal mammogram. Therefore, the mammogram is 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 coinsurance forthe mammogram, the ultrasounds, or the laboratory work provided on July 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee's therapists feel IRF is the best option.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee had a stroke in May of 2019 and was found to have bleeding in the brain (subdural hematoma) with surgical intervention. He had rehabilitation until August 31, 2019 and was discharged home. He continues to receive tube feedings and needs maximum assistance with bed mobility and basic activities of daily living. He is non-ambulatory. His condition is stable and he has no wound care needs. He does not require medical oversight of his condition at an acute hospital level of care. He requires further therapy but does not require an intensive therapy program in an IRF and may not be able to fully participate in and benefit from an IRF program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe GeneSight Psychotropic Assay.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that the GeneSight Psychotropic Assay is covered when specific criteria are met.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the testing is not medicallynecessary. Our physician reviewer found the enrollee has a diagnosis of bipolar disorder with current manic episode with psychotic features, generalized anxiety disorder, and unspecified sleep disorder. There is no diagnoses of major depressive disorder, as required by the Medicare rules. GeneSight testing is therefore not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvethe GeneSight Psychotropic Assay.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair electronic upgrades.You asked the Plan to pre-approvethe power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). You say that the enrollee needs to independently control the power options through the joystick.The Plan denied your request. The Plan says although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. The power options come with their own switches.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Documentation shows that the enrollee has normal range of motion and 4/5 strength in the bilateral upper limbs. Upper limb strength and range of motion are adequate for the enrolleeto be able to control the power options using their own switches which are included in the allowance of these power options. Based on this information, we decided that Medicare rules for coverage of the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377) have not been met.Therefore, we decided that the Plan does not have to pre-approvethe power wheelchair electronic upgrades.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services provided on August 6, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysHealthcare Common Procedural Coding System (HCPCS) code G0483 (1 Unit) remains not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.In this case, the definition of HCPCS G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3)method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the submitted medical records did not include an order and results for 22 or more drug class(es), including metabolite was performed. Of note, the appropriate HCPCS code G0482 should be billed for the services performed. Therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. The review has determined that the records did not support the coding of HCPCS G0483.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 Plandoes not haveto pay fordrug testing services provided on August 6, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lunesta for the enrollee.You asked the Plan to pre-approve Lunesta. You say that the enrollee has chronic insomnia.The Plan denied your request. The Plan says that this medication 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-approveLunesta for the enrollee.Benefits for Lunestamay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe infliximab injections provided on June 6, 2019 and June 24, 2019.You asked the Plan to waive the coinsurance forthe infliximab injections. You say that the costs have been aburden. You say that you want the coinsurance reduced.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 chemotherapy drugs and all other drugs covered under Medicare Part B from an in-network provider.You have been asked to pay $1,349.04, which is 20% of the allowed amount for each infliximab injection. The allowed amount is $6,745.20 (20% x $6,745.20 = $1,349.04). The total amount you owe is $2,698.08 ($1,349.04/injection x 2 injections = $2,698.08).The infliximab injections fall within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance forthe infliximab injections provided on June 6, 2019 and June 24, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe physical exam (CPT 99397) provided to you on August 19, 2019.You asked the Plan to pay forthe exam. The Plan denied your request. The Plan says that this is not a covered service.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.The plan follows these rules.You were provided the exam by a contract provider. You went to see this provider for an annual wellness visit. The provider also billed a physical exam. The file does not show that the plan provided notice that the exam would not be covered. Under Medicare rules, this means the exam is considered approved by the plan.Therefore, we decided that the Plan has to pay forthe physical exam (CPT 99397) provided to you on August 19, 2019
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-approvefoot orthotics. You say that your inserts are worn out and you require them for ambulating and completing your work.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-approvefoot orthotics.